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Mental Health: 

A Report of the 

Surgeon General 




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Mental 
Health 



A Report of the Surgeon General 



DEPARTMENT OF HEALTH AND HUMAN SERVICES 
U.S. Public Health Service 




The Center for Mental Health Services 

Substance Abuse and Mental Health 
Services Administration 



m} II 

National Institute 
of Mental Health 

National Institutes of Health 



Suggested Citation 

U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon 
General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and 
Mental Health Services Administration, Center for Mental Health Services, National Institutes of 
Health, National Institute of Mental Health, 1999. 



For sale by the U.S. Government Printing Office 

Superintendent of Documents, Mail Stop: SSOP, Washington, DC 20402-9328 

ISBN 0-16-050300-0 



Message from Donna E. Shalala 

Secretary of Health and Human Services 

The United States leads the world in understanding the importance of overall health and well- 
being to the strength of a Nation and its people. What we are coming to realize is that mental health 
is absolutely essential to achieving prosperity. According to the landmark "Global Burden of 
Disease" study, commissioned by the World Health Organization and the World Bank, 4 of the 10 
leading causes of disability for persons age 5 and older are mental disorders. Among developed 
nations, including the United States, major depression is the leading cause of disability. Also near 
the top of these rankings are manic-depressive illness, schizophrenia, and obsessive-compulsive 
disorder. Mental disorders also are tragic contributors to mortality, with suicide perennially 
representing one of the leading preventable causes of death in the United States and worldwide. 

The U.S. Congress declared the 1990s the Decade of the Brain. In this decade we have learned 
much through research — in basic neuroscience, behavioral science, and genetics — about the complex 
workings of the brain. Research can help us gain a further understanding of the fundamental 
mechanisms underlying thought, emotion, and behavior — and an understanding of what goes wrong 
in the brain in mental illness. It can also lead to better treatments and improved services for our 
diverse population. 

Now, with the publication of this first Surgeon General's Report on Mental Health, we are 
poised to take what we know and to advance the state of mental health in the Nation. We can with 
great confidence encourage individuals to seek treatment when they find themselves experiencing 
the signs and symptoms of mental distress. Research has given us effective treatments and service 
delivery strategies for many mental disorders. An array of safe and potent medications and 
psychosocial interventions, typically used in combination, allow us to effectively treat most mental 
disorders. 

This seminal report provides us with an opportunity to dispel the myths and stigma surrounding 
mental illness. For too long the fear of mental illness has been profoundly destructive to people's 
lives. In fact mental illnesses are just as real as other illnesses, and they are like other illnesses in 
most ways. Yet fear and stigma persist, resulting in lost opportunities for individuals to seek 
treatment and improve or recover. 

In this Administration, a persistent, courageous advocate of affordable, quality mental health 
services for all Americans is Mrs. Tipper Gore, wife of the Vice President. We salute her for her 
historic leadership and for her enthusiastic support of the initiative by the Surgeon General, Dr. 
David Satcher, to issue this groundbreaking Report on Mental Health. 

The 1999 White House Conference on Mental Health called for a national antistigma campaign. 
The Surgeon General issued a Call to Action on Suicide Prevention in 1999 as well. This Surgeon 
General' s Report on Mental Health takes the next step in advancing the important notion that mental 
health is fundamental health. 



Foreword 

Since the turn of this century, thanks in large measure to research-based pubhc health 
innovations, the lifespan of the average American has nearly doubled. Today, our Nation's physical 
health — as a whole — has never been better. Moreover, illnesses of the body, once shrouded in 
fear — such as cancer, epilepsy, and HIV/ AIDS to name just a few — increasingly are seen as treatable, 
survivable, even curable ailments. Yet, despite unprecedented knowledge gained in just the past three 
decades about the brain and human behavior, mental health is often an afterthought and illnesses of 
the mind remain shrouded in fear and misunderstanding. 

This Report of the Surgeon General on Mental Health is the product of an invigorating 
collaboration between two Federal agencies. The Substance Abuse and Mental Health Services 
Administration (SAMHSA), which provides national leadership and funding to the states and many 
professional and citizen organizations that are striving to improve the availability, accessibility, and 
quality of mental health services, was assigned lead responsibiUty for coordinating the development 
of the report. The National Institutes of Health (NIH), which supports and conducts research on 
mental illness and mental health through its National Institute of Mental Health (NIMH), was pleased 
to be a partner in this effort. The agencies we respectively head were able to rely on the enthusiastic 
participation of hundreds of people who played a role in researching, writing, reviewing, and 
disseminating this report. We wish to express our appreciation and that of a mental health 
constituency, millions of Americans strong, to Surgeon General David Satcher, M.D., Ph.D., for 
inviting us to participate in this landmark report. 

The year 1999 witnessed the first White House Conference on Mental Health and the first 
Secretarial Initiative on Mental Health prepared under the aegis of the Department of Health and 
Human Services. These activities set an optimistic tone for progress that will be realized in the years 
ahead. Looking ahead, we take special pride in the remarkable record of accomplishment, in the 
spheres of both science and services, to which our agencies have contributed overpast decades. With 
the impetus that the Surgeon General's report provides, we intend to expand that record of 
accomplishment. This report recognizes the inextricably intertwined relationship between our mental 
health and our physical health and well-being. The report emphasizes that mental health and mental 
illnesses are important concerns at all ages. Accordingly, we will continue to attend to needs that 
occur across the lifespan, from the youngest child to the oldest among us. 

The report lays down a challenge to the Nation — to our communities, our health and social 
service agencies, our policymakers, employers, and citizens — to take action. SAMHSA and NIH look 
forward to continuing our collaboration to generate needed knowledge about the brain and behavior 
and to translate that knowledge to the service systems, providers, and citizens. 



Nelba Chavez, Ph.D. 
Administrator 

Substance Abuse and Mental Health 
Services Administration 



Steven E. Hyman, M.D. 

Director 

National Institute of Mental Health 

for The National Institutes of Health 



Bernard S. Arons, M.D. 

Director 

Center for Mental Health Services 



Preface 

from the Surgeon General 
U.S. Public Health Service 

The past century has witnessed extraordinary progress in our improvement of the pubhc heahh 
through medical science and ambitious, often innovative, approaches to health care services. Previous 
Surgeons General reports have saluted our gains while continuing to set ever higher benchmarks for 
the public health. Through much of this era of great challenge and greater achievement, however, 
concerns regarding mental illness and mental health too often were relegated to the rear of our 
national consciousness. Tragic and devastating disorders such as schizophrenia, depression and 
bipolar disorder, Alzheimer's disease, the mental and behavioral disorders suffered by children, and 
a range of other mental disorders affect nearly one in five Americans in any year, yet continue too 
frequently to be spoken of in whispers and shame. Fortunately, leaders in the mental health 
field — fiercely dedicated advocates, scientists, government officials, and consumers — have been 
insistent that mental health flow in the mainstream of health. I agree and issue this report in that spirit. 

This report makes evident that the neuroscience of mental health — a term that encompasses 
studies extending from molecular events to psychological, behavioral, and societal phenomena — has 
emerged as one of the most exciting arenas of scientific activity and human inquiry. We recognize 
that the brain is the integrator of thought, emotion, behavior, and health. Indeed, one of the foremost 
contributions of contemporary mental health research is the extent to which it has mended the 
destructive split between "mental" and "physical" health. 

We know more today about how to treat mental illness effectively and appropriately than we 
know with certainty about how to prevent mental illness and promote mental health. Common sense 
and respect for our fellow humans tells us that a focus on the positive aspects of mental health 
demands our immediate attention. 

Even more than other areas of health and medicine, the mental health field is plagued by 
disparities in the availability of and access to its services. These disparities are viewed readily through 
the lenses of racial and cultural diversity, age, and gender. A key disparity often hinges on a person's 
financial status; formidable financial barriers block off needed mental health care from too many 
people regardless of whether one has health insurance with inadequate mental health benefits, or is 
one of the 44 milHon Americans who lack any insurance. We have allowed stigma and a now 
unwarranted sense of hopelessness about the opportunities for recovery from mental illness to erect 
these barriers. It is time to take them down. 

Promoting mental health for all Americans will require scientific know-how but, even more 
importantly, a societal resolve that we will make the needed investment. The investment does not call 
for massive budgets; rather, it calls for the willingness of each of us to educate ourselves and others 
about mental health and mental illness, and thus to confront the attitudes, fear, and misunderstanding 
that remain as barriers before us. It is my intent that this report will usher in a healthy era of mind and 
body for the Nation. 

David Satcher, M.D., Ph.D. 
Surgeon General 



Acknowledgments 



Acknowledgments 



I 



This report was prepared by the Department of 
Health and Human Services under the direction of 
the Substance Abuse and Mental Health Services 
Administration, Center for Mental Health Services, 
in partnership with the National Institute of Mental 
Health, National Institutes of Health. 

Nelba Chavez, Ph.D., Administrator, Substance 
Abuse and Mental Health Services Administration, 
Rockville, Maryland. 

Harold E. Varmus, M.D., Director, National 
Institutes of Health, Bethesda, Maryland. 

Bernard Arons, M.D., Director, Center for Mental 
Health Services, Substance Abuse and Mental Health 
Services Administration, Rockville, Maryland. 

Steven Hyman, M.D., Director, National Institute of 
Mental Health, National Institutes of Health, 
Bethesda, Maryland. 

RADM Thomas Bornemann, Ed.D., Deputy Director, 
Center for Mental Health Services, Substance Abuse 
and Mental Health Services Administration, 
Rockville, Maryland. 

Richard Nakamura, Ph.D., Deputy Director, National 
Institute of Mental Health, National Institutes of 
Health, Bethesda, Maryland. 

RADM Kenneth Moritsugu, M.D., M.P.H., Deputy 
Surgeon General, Office of the Surgeon General, 
Office of the Secretary, Rockville, Maryland. 

RADM Susan Blumenthal, M.D., M.P.A., Assistant 
Surgeon General and Senior Science Advisor, Office 
of the Surgeon General, Office of the Secretary, 
Rockville, Maryland. 



Nicole Lurie, M.D., M.S.P.H., Principal Deputy 
Assistant Secretary for Health, Office of Public 
Health and Science, Office of the Secretary, 
Washington, D.C. 

RADM Arthur Lawrence, Ph.D., Deputy Assistant 
Secretary for Health, Office of Public Health and 
Science, Office of the Secretary, Washington, D.C. 

Virginia Trotter Betts, M.S.N., J.D., R.N., F.A.A.N., 
Senior Advisor on Nursing and Policy, Office of 
Public Health and Science, Office of the Secretary, 
Washington, D.C. 



Editors 

Howard H. Goldman, M.D., Ph.D., Senior Scientific 
Editor, Professor of Psychiatry, University of Mary- 
land School of Medicine, Baltimore, Maryland. 

CAPT Patricia Rye, J.D., M.S.W., Managing Editor, 
Office of the Director, Center for Mental Health 
Services, Substance Abuse and Mental Health 
Services Administration, Rockville, Maryland. 

Paul Sirovatka, M.S., Coordinating Editor, Science 
Writer, Office of Science Policy and Program 
Planning, National Institute of Mental Health, 
National Institutes of Health, Bethesda, Maryland. 



Section Editors 

Jeffrey A. Buck, Ph.D., Director, Office of Managed 
Care, Center for Mental Health Services, Substance 
Abuse and Mental Health Services Administration, 
Rockville, Maryland. 

CAPT Peter Jensen, M.D., Associate Director for 
Child and Adolescent Research, National Institute of 
Mental Health, National Institutes of Health, 
Bethesda, Maryland. 



Vll 



Mental Health: A Report of the Surgeon General 



Judith Katz-Leavy, M.Ed., Senior Policy Analyst, 
Office of Policy, Planning and Administration, Center 
for Mental Health Services, Substance Abuse and 
Mental Health Services Administration, Rockville, 
Maryland. 

Barry Lebowitz, Ph.D., Chief, Adult and Geriatric 
Treatment and Preventive Intervention Research 
Branch, Division of Services and Intervention Research, 
National Institute of Mental Health, National Institutes 
of Health, Bethesda, Maryland. 

Ronald W. Manderscheid, Ph.D., Chief, Survey and 
Analysis Branch, Center for Mental Health Services, 
Substance Abuse and Mental Health Services 
Administration, Rockville, Maryland. 



Planning Board 

Mary Lou Andersen, Deputy Director, Bureau of 
Primary Health Care, Health Resources and Services 
Administration, Bethesda, Maryland. 

Andrea Baruchin, Ph.D., Chief, Science Policy Branch, 
Office of Science Policy and Communication, National 
Institute on Drug Abuse, National Institutes of Health, 
Bethesda, Maryland. 

Michael Benjamin, M.P.H., Executive Director, 
National Council on Family Relations, Minneapolis, 
Minnesota. 

Robert Bernstein, Ph.D., Executive Director, Bazelon 
Center, Washington, D.C. 



RADM Darrel Regier, M.D., M.P.H., Associate 
Director, Epidemiology and Health Policy Research, 
National Institute of Mental Health, National Institutes 
of Health, Bethesda, Maryland. 



Gene Cohen, M.D., Ph.D., Director, George 
Washington University Center on Aging, Health and 
Humanities; Director, Washington D.C. Center on 
Aging, Washington, D.C. 



Matthew V. Rudorfer, M.D., Associate Director for 
Treatment Research, Division of Services and 
Intervention Research, National Institute of Mental 
Health, National Institutes of Health, Bethesda, 
Maryland. 



Senior Science Writer 

Miriam Davis, Ph.D., Medical Writer and Consultant, 
Silver Spring, Maryland. 



Science Writers 

Birgit An der Lan, Ph.D., Science Writer, Bethesda, 
Maryland. 

Anne H. Rosenfeld, Special Assistant to the Director, 
Division of Mental Disorders, Behavioral Research and 
AIDS, National Institute of Mental Health, National 
Institutes of Health, Bethesda, Maryland. 



Judith Cook, Ph.D., Director, National Research and 
Training Center on Psychiatric Disability; Professor, 
Department of Psychiatry, University of Illinois at 
Chicago, Chicago, Illinois. 

Margaret Coopey, R.N., Senior Health Policy Analyst, 
Director, Center for Practice and Technology 
Assessment, Agency for Health Care Policy and 
Research, Rockville, Maryland. 

Gail Daniels, Board President, The Federation of 
Families for Children's Mental Health, Washington, 
D.C. 

Paolo Del Vecchio, M.S.W., Senior Policy Analyst, 
Office of Policy, Planning, and Administration, Center 
for Mental Health Services, Substance Abuse and 
Mental Health Services Administration, Rockville, 
Maryland. 

Michael Eckardt, Ph.D., Senior Science Advisor, Office 
of Scientific Affairs, National Institute on Alcohol 
Abuse and Alcoholism, National Institutes of Health, 
Rockville, Maryland. 



Vlll 



Acknowledgments 



Mary Jane England, M.D., President, Washington 
Business Group on Health, Washington, D.C. 

Michael English, J.D., Director, Division of Knowledge 
Development and Systems Change, Center for Mental 
Health Services, Substance Abuse and Mental Health 
Services Administration, Rockville, Maryland. 

Michael M. Faenza, M.S.S.W., President and Chief 
Executive Officer, National Mental Health Association, 
Alexandria, Virginia. 

Michael Fishman, M.D., Assistant Director, Division of 
Child, Adolescent and Family Health, Bureau of 
Maternal and Child Health, Health Resources and 
Services Administration, Rockville, Maryland. 

Laurie Flynn, Executive Director, National Alliance for 
the Mentally 111, Arlington, Virginia. 



Elliott Heiman, M.D., Chief of Staff of Psychiatry, St. 
Mary's Hospital, Tucson, Arizona. 

Kevin Hennessy, M.P.P., Ph.D., Health Policy Analyst, 
Office of the Assistant Secretary for Planning and 
Evaluation, Office of the Secretary, Washington, D.C. 

Pablo Hernandez, M.D., Administrator, Wyoming State 
Commission for Mental Health, Division of Behavioral 
Health, Evanston, Wyoming. 

Thomas Horvath, M.D., Chief of Staff, Houston 
Veterans Affairs Medical Center, Houston, Texas. 

J. Rock Johnson, J.D., Consultant, Lincoln, Nebraska. 

Miriam Kelty, Ph.D., Associate Director for Extramural 
Affairs, National Institute on Aging, National Institutes 
of Health, Bethesda, Maryland. 



Larry Fricks, Director, Office of Consumer Relations, 
Georgia Division of Mental Health, Atlanta, Georgia. 

Robert Friedman, Ph.D., Director, Research and 
Training Center for Children's Mental Health, Florida 
Mental Health Institute, University of South Florida, 
Tampa, Florida. 

Laurie Garduque, Ph.D., Senior Program Officer, 
Program and Community Development, MacArthur 
Foundation, Chicago, Illinois. 

John J. Gates, Ph.D., Director of Programs, 
Collaborative Center for Child Well-being, Decatur, 
Georgia. 

Rosa M. Gil, D.S.W., Special Advisor to the Mayor for 
Health Policy, New York City Mayor' s Office of Health 
Services, New York, New York. 

Barbara Gill, M.B.A., Executive Director, Dana 
Alliance for Brain Initiatives, New York, New York. 



Lloyd Kolbe, Ph.D., Director, Division of Adolescent 
and School Health, National Center for Chronic Disease 
Prevention and Health Promotion, Centers for Disease 
Control and Prevention, Atlanta, Georgia. 

Jeffrey Lieberman, M.D., Vice Chairman of Research, 
University of North Carolina, Department of Psychiatry, 
Chapel Hill, North Carolina. 

Spero Manson, Ph.D., Director, Division of American 
Indian and Alaska Native Programs, University of 
Colorado Health Science Center, Department of 
Psychiatry, Denver, Colorado. 

RADM C. Beth Mazzella. R.N., Ph.D., Chief Nurse 
Officer, Office of the Administrator, Health Resources 
and Services Administration, Rockville, Maryland. 

Bruce McEwen, Ph.D., Professor and Head of the Lab 
for Neuroendocrinology, Rockefeller University, New 
York, New York. 



Mary Harper, R.N., Ph.D., Gerontologist, Tuscaloosa, 
Alabama. 



IX 



Mental Health: A Report of the Surgeon General 



Herbert Pardes, M.D., Vice President for Health 
Sciences and Dean of the Faculty of Medicine, 
Columbia University Health Sciences Center, New 
York, New York. 



Participants in Developing the Report 

Norman Abeles, Ph.D., Department of Psychology, 
Michigan State University, East Lansing, Michigan. 



Ruth Ralph, Ph.D., Research Associate, Edmund S. 
Muskie School of Public Service, University of 
Southern Maine, Portland, Maine. 

The Honorable Robert Ray, Former Governor, State of 
Iowa, Des Moines, Iowa. 

Corinne Rieder, Ed.D., Executive Director, John A. 
Hartford Foundation, New York, New York. 

Mona Rowe, M.C.P., Deputy Director, Office of 
Science Policy, Analysis, and Communication, National 
Institute of Child Health and Human Development, 
National Institutes of Health, Bethesda, Maryland. 



Catherine Acuff, Ph.D., Senior Health Policy Analyst, 
Office of the Director, Center for Mental Health 
Services, Substance Abuse and Mental Health Services 
Administration, Rockville, Maryland. 

Laurie Ahem, Director, National Empowerment Center, 
Inc., Lawrence, Massachusetts. 

Marguerite Alegria, Ph.D., University of Puerto Rico, 
Medical Sciences Campus, School of Public Health, 
San Juan, Puerto Rico. 

Rene Andersen, M.Ed., Human Resource Association 
of the Northeast, Holyoke, Massachusetts. 



Steve Schreiber, M.D., Associate Professor of 
Neurology, Cell and Neurobiology, University of 
Southern California School of Medicine, Department of 
Neurology, Los Angeles, California. 

Steven A. Schroeder, M.D., President, Robert Wood 
Johnson Foundation, Princeton, New Jersey. 



Thomas E. Arthur, M.H.A., Coordinator of Consumer 
Affairs, Maryland Health Partners, Columbia, 
Maryland. 

RosinaBecerra, Ph.D., Professor, Department of Social 
Welfare, Center for Child and Family Policy, University 
of California at Los Angeles, Los Angeles, California. 



Brent Stanfield, Ph.D., Director, Office of Science 
Policy and Program Planning, National Institute of 
Mental Health, National Institutes of Health, Bethesda, 
Maryland. 

Stanley Sue, Ph.D., Professor of Psychology and 
Psychiatry, Director, Asian American Studies Program, 
Department of Psychology, University of California at 
Davis, Davis, California. 

Jeanette Takamura, Ph.D., Assistant Secretary for 
Aging, Administration on Aging, Washington, D.C. 

Roy C. Wilson, M.D., Director, Missouri Department of 
Mental Health, Jefferson City, Missouri. 



Cornelia Beck, R.N., F.A.A.N., Ph.D., College of 
Nursing, University of Arkansas for Medical Services, 
Little Rock, Arkansas. 

Peter G. Beeson, Ph.D., Administrator, Strategic 
Management Services, Nebraska Health and Human 
Services Finance and Support Agency, Lincoln, 
Nebraska. 

Leonard Bickman, Ph.D., Professor of Psychology, 
Center for Mental Health Policy, Institute for Public 
Policy Studies, Vanderbilt University, Nashville, 
Tennessee. 

Robert Boorstin, Senior Advisor to the Secretary of 
the Treasury, Department of the Treasury, 
Washington, D.C. 



Acknowledgments 



David Brown, Consultant, Survey and Analysis 
Branch, Division of State and Community Systems 
Development, Center for Mental Health Services, 
Substance Abuse and Mental Health Services 
Administration, Rockville, Maryland. 

Barbara J. Burns, Ph.D., Professor of Medical 
Psychology, Department of Psychiatry and Behavioral 
Sciences, Duke University Medical Center, Durham, 
North Carolina. 

Jean Campbell, Ph.D., Research Assistant Professor, 
Missouri Institute of Mental Health, School of 
Medicine, University of Missouri-Columbia, St. 
Louis, Missouri. 

Josefina Carbonell, President, Little Havana Activities 
and Nutrition Centers of Dade County, Inc., Miami, 
Florida. 



Lisa Dixon, M.D., Associate Professor, Center for 
Mental Health Services Research; Director of 
Education, Department of Psychiatry, University of 
Maryland School of Medicine, Baltimore, Maryland. 

Susan Dubuque, President, Market Strategies, Inc., 
Richmond, Virginia. 

Mina K. Dulcan, M.D., Head, Department of Child 
and Adolescent Psychiatry, Children's Memorial 
Hospital, Chicago, Illinois. 

Nellie Fox Edvi'ards, American Association of Retired 
Persons, Beaverton, Oregon. 

Lisa T. Eyler-Zorrilla, Ph.D., Post-Doctoral Fellow, 
Geriatric Psychiatry Clinical Research Center, 
Department of Psychiatry, University of 
California-San Diego, La Jolla, California. 



Elaine Carmen, M.D., Medical Director, Brockton 
Multi Service Center, Brockton, Massachusetts. 

H. Westley Clark, M.D., J.D., M.P.H., Director, 
Center for Substance Abuse Treatment, Substance 
Abuse and Mental Health Services Administration, 
Rockville, Maryland. 



Theodora Fine, M.A., Special Assistant to the 
Director, Office of the Director, Center for Mental 
Health Services, Substance Abuse and Mental Health 
Services Administration, Rockville, Maryland. 

Dan Fisher, M.D., Ph.D., Executive Director, National 
Empowerment Center, Inc., Lawrence, Massachusetts. 



Donald J. Cohen, M.D., Professor of Child and 
Adolescent Psychiatry, Yale University School of 
Medicine, New Haven, Connecticut. 



Richard G. Frank, Ph.D., Professor of Health 
Economics, Department of Health Care Policy, 
Harvard University, Boston, Massachusetts. 



Judith Cohen, Ph.D., Director, Association for 
Women's AIDS Risk Education, Corte Madera, 
California. 

King Davis, Ph.D., William and Camille Cosby 
Scholar, Howard University, Washington, D.C. 

Laura A. DeRiggi, L.S.W., M.S.W., Clinical Director, 
Community Behavioral Health, Philadelphia, 
Pennsylvania. 



I 



Barbara Friesen, Ph.D., Director, Research and 
Training Center, Family Support and Children's 
Mental Health, Portland State University, Portland, 
Oregon. 

Darrell Gaskin, Ph.D., Research Assistant Professor, 
Institute for Health Care Research and Policy, 
Georgetown University Medical Center, Washington, 
D.C. 

Mary Jo Gibson, Ph.D., Associate Director of Public 
Policy Institute, AARP, Washington, D.C. 



XI 



Mental Health: A Report of the Surgeon General 



Sherry Glied, Ph.D., Associate Professor and Head, 
Division of Health Policy and Management, Joseph L. 
Mailman School of Public Health, Columbia 

University, New York, New York. 



Mario Hernandez, Ph.D., Director, Division of 
Training, Research, Evaluation and Demonstrations, 
Department of Child and Family Studies, Florida 
Mental Health Institute, Tampa, Florida. 



Margo Goldman, M.D., Policy Director, National 
Coalition for Patients' Rights, Lexington, 
Massachusetts. 

Junius Gonzales, M.D., Deputy Chairman, Psychiatry 
Department, Georgetown University, Washington, 
D.C. 



Kimberly Hoagwood, Ph.D., Associate Director, Child 
and Adolescent Research, National Institute of Mental 
Health, National Institutes of Health, Bethesda, 
Maryland. 

Ron Honberg, Director of Legal Affairs, National 
Alliance for the Mentally 111, Arlington, Virginia. 



Jack Gorman, M.D., Professor of Psychiatry, 
Columbia University; Deputy Director, New York 
State Psychiatric Institute, New York, New York. 



Teh-wei Hu, Ph.D., Professor of Health Economics, 
School of Public Health, University of 
California-Berkeley, Berkeley, California. 



Barbara Guthrie, Ph.D., R.N., University of Michigan 
School of Nursing, Ann Arbor, Michigan. 



Edwin C. Hustead, Senior Consultant, Hay Group, 
Inc., Washington, D.C. 



Jennifer Gutstein, Research Assistant, Department of 
Child Psychiatry, Columbia University, New York, 
New York. 

Laura Lee Hall, Ph.D., Deputy Director of Policy and 
Research, National Alliance for the Mentally 111, 
Arlington, Virginia. 

Richard K. Harding, M.D., Medical Director, 
Psychiatric Services, Richland Springs Hospital, 
Columbia, South Carolina. 

Herbert W. Harris, M.D., Ph.D., Chief, Geriatric 
Pharmacology Programs, Adult and Geriatric 
Treatment and Preventive Intervention Research 
Branch, Division of Services and Intervention 
Research, National Institute of Mental Health, 
National Institutes of Health, Bethesda, Maryland. 



Dilip V. Jeste, M.D., Director, Geriatric Psychiatry 
Clinical Research Center, University of California at 
San Diego, Veterans Affairs Medical Center 
Psychiatry Service, San Diego, California. 

Ira Katz, M.D., Ph.D., Professor of Psychiatry, 
Director, Section on Geriatric Psychiatry, University 
of Pennsylvania, Philadelphia, Pennsylvania. 

Kelly J. Kelleher, M.D., Staunton Professor of 
Pediatrics, Psychiatry and Health Services, Schools of 
Medicine and Public Health, Departments of 
Pediatrics and Psychiatry, University of Pittsburgh, 
Pittsburgh, Pennsylvania. 

Chris Koyanagi, Director of Legislative Policy, 
Bazelon Center for Mental Health Law, Washington, 
D.C. 



Seth Hassett, M.S.W., Public Health Advisor, 
Emergency Services and Disaster Relief Branch, 
Division of Program Development, Special 
Populations and Projects, Center for Mental Health 
Services, Substance Abuse and Mental Health 
Services Administration, Rockville, Maryland. 



Celinda Lake, M.P.S., President and Founder, Lake 
Snell Perry and Associates, Inc., Washington, D.C. 

Christopher Langston, Ph.D., Program Officer, John 
A. Hartford Foundation, New York, New York. 



xu 



Acknowledgments 



John B. Lavigne, Ph.D., Chief Psychologist, 
Department of Child and Adolescent Psychiatry, 
Children's Memorial Hospital, Chicago, Illinois. 



Denise Nagel, M.D., Executive Director, National 
Coalition for Patients' Rights, Lexington, 
Massachusetts. 



Anthony Lehman, M.D., Director, Center for Mental 
Health Services Research, University of Maryland 
School of Medicine, Baltimore, Maryland. 

Keh-Ming Lin, M.D., M.P.H., Director of Research 
Center on the Psychobiology of Ethnicity, Professor 
of Psychiatry, University of California at Los Angeles 
School of Medicine, Harbor-University of California 
at Los Angeles Medical Center, Torrance, California. 

Steven Lopez, Ph.D., Clinical Psychologist, 
Department of Psychology, University of California at 
Los Angeles, Los Angeles, California. 



Ira Lourie, M.D., Partner, Human 
Collaborative, Rockville, Maryland. 



Service 



William Narrow, M.D., M.P.H., Senior Advisor for 
Epidemiology, Office of the Associate Director for 
Epidemiology and Health Policy Research, National 
Institute of Mental Health, National Institutes of 
Health, Bethesda, Maryland. 

Cassandra F. Newkirk, M.D., Forensic Psychiatrist 
and Consultant, Caldwell, New Jersey. 

Silvia W. Orlate, M.D., Clinical Professor of 
Psychology, New York Medical CoUege-Vahalla, 
New York, New York. 

Trina Osher, M.S.W., Coordinator of Policy and 
Research, Federation of Families for Children's 
Mental Health, Alexandria, Virginia. 



Francis Lu, M.D., Director of Cultural Competence 
and Diversity Program, Department of Psychiatry, San 
Francisco General Hospital, San Francisco, California. 

Alicia Lucksted, Ph.D., Senior Research Associate, 
Department of Psychiatry, University of Maryland, 
Baltimore, Maryland. 



John Petrila, J.D., L.L.M., Chairman and Professor, 
Department of Mental Health Law and Policy, 
University of South Florida, Florida Mental Health 
Institute, Tampa, Florida. 

RADM Retired William Prescott, M.D.. Psychiatrist, 
Brook Lane Health Service, Hagerstown, Maryland. 



Bryce Miller, Consultant, National Alliance for the 
Mentally 111, Topeka, Kansas. 

Jeanne Miranda, Ph.D., Associate Professor, 
Psychiatry Department, Georgetown University, 
Washington, D.C. 

Joseph P. Morrissey, Ph.D., Deputy Director, Senior 
Fellow, Sheps Center for Health Services Research, 
University of North Carolina at Chapel Hill, Chapel 
Hill, North Carolina. 

Patricia J. Mrazek, Ph.D., President, Scientific 
Director, Prevention Technologies, LLC, Bethesda, 
Maryland. 



Juan Ramos, Ph.D., Associate Director for Prevention, 
National Institute of Mental Health, National 
Institutes of Health, Bethesda, Maryland. 

Burton Reifler, M.D., Professor and Chairman, 
Department of Psychiatry, Wake Forest University 
School of Medicine, Winston-Salem, North Carolina. 

Donald J. Richardson, Ph.D., The Carter Center 
National Advisory Council; Co-founder and Vice 
President, National Alliance for Research on 
Schizophrenia and Depression, Los Angeles, 
California. 

Jean Risman, Consumer Researcher, North Berwick, 
Maine. 



Xlll 



Mental Health: A Report of the Surgeon General 



Ariela C. Rodriguez, Ph.D., L.C.S.W., A.C.S.W., 
Director, Health and Social Services, Little Havana 
Activities and Nutrition Centers of Dade County, Inc., 
Miami, Florida. 

Gloria Rodriguez, Ph.D., President and Chief 
Executive Officer, Avance Corporation, San Antonio, 
Texas. 

Abram Rosenblatt, Ph.D., Research Director, 
University of California at San Francisco Child 
Services Research Group, San Francisco, California 



Jurgen Unutzer, M.D., M.P.H., M.A., Assistant 
Professor in Residence, Department of Psychiatry, 
University of California at Los Angeles 
Neuropsychiatric Institute, Center for Health Services 
Research, Los Angeles, California. 

Laura Van Tosh, Consultant, Silver Spring, Maryland. 

Joan Ellen Zweben, Ph.D., Clinical Professor, 
Department of Psychiatry, School of Medicine, 
University of California-San Francisco, Berkeley, 
California. 



Agnes E. Rupp, Ph.D., Senior Economist and Chief, 
Financing and Managed Care Research Program, 
Services Research and Clinical Epidemiology Branch, 
Division of Services and Intervention Research, 
National Institute of Mental Health, National 
Institutes of Health, Bethesda, Maryland. 



Other Participants 

Joan G. Abell, Chief, Information Resources and 
Inquiries Branch, National Institute of Mental Health, 
National Institutes of Health, Bethesda, Maryland. 



A. John Rush, M.D., Professor of Psychiatry, 
University of Texas Southwest Medical Center, 
Department of Psychiatry, Dallas, Texas. 

David Shaffer, M.D., Professor of Psychiatry and 
Pediatrics, Director, Division of Child and Adolescent 
Psychiatry, Columbia University, New York, New 
York. 

David Shore, M.D., Associate Director for Clinical 
Research, Office of the Director, National Institute of 
Mental Health, National Institutes of Health, 
Bethesda, Maryland. 

Lonnie Snowden, Ph.D., Professor, School of Social 
Welfare, University of California-Berkeley; Director, 
Center for Mental Health Services Research, 
Berkeley, California. 

George Strieker, Ph.D., Distinguished Research 
Professor of Psychology, Derner Institute, Adelphi 
University, Garden City, New York. 

Michael E. Thase, M.D., Professor of Psychiatry, 
University of Pittsburgh School of Medicine, 
Pittsburgh, Pennsylvania. 



Curtis Austin, Director, Office of External Liaison, 
Center for Mental Health Services, Substance Abuse 
and Mental Health Services Administration, 
Rockville, Maryland. 

Elaine Baldwin, M.Ed., Chief, Public Affairs and 
Science Reports Branch, Office of Scientific 
Information, National Institute of Mental Health, 
National Institutes of Health, Bethesda, Maryland. 

Leslie Bassett, Program Assistant, Office of the 
Director, Center for Mental Health Services, 
Substance Abuse and Mental Health Services 
Administration, Rockville, Maryland. 

Bonni Bennett, Desktopping Specialist, R.O.W. 
Sciences, Inc., Rockville, Maryland. 

Margaret Blasinsky, M.A., Vice President, R.O.W. 
Sciences, Inc., Rockville, Maryland. 

Anne B. Carr (formerly Program Assistant, Office of 
the Director, Center for Mental Health Services, 
Substance Abuse and Mental Health Services 
Administration), Silver Spring, Maryland. 



XIV 



Acknowledgments 



Lemuel B. Clark, M.D., Chief, Community Mental 
Health Centers Constniction Monitoring Branch, 
Division of Program Development, Special 
Populations and Projects, Center for Mental Health 
Services, Substance Abuse and Mental Health 
Services Administration, Rockville, Maryland. 

Olavo Da Rocha, Graphic Designer, R.O.W. Sciences, 
Inc., Rockville, Maryland. 

Daria Donaldson, Editor, R.O.W. Sciences, Inc., 
Rockville, Maryland. 



Michael Maiden, Public Affairs Specialist, 
Knowledge Exchange Network, Office of External 
Liaison, Center for Mental Health Services, Substance 
Abuse and Mental Health Services Administration, 
Rockville, Maryland. 

Anne Matthews-Younes, Ed.D., Chief, Special 
Programs Development Branch, Division of Program 
Development, Special Populations and Projects, 
Center for Mental Health Services, Substance Abuse 
and Mental Health Services Administration, 
Rockville, Maryland. 



Betsy Furin, Program Assistant, Community Mental 
Health Centers Construction Monitoring Branch, 
Division of Program Development, Special 
Populations and Projects, Center for Mental Health 
Services, Substance Abuse and Mental Health 
Services Administration, Rockville, Maryland. 

David Fry, Consultant Writer, Cabin John, Maryland. 



Kevin McGowan, Contract Specialist, General 
Acquisitions Branch, Division of Acquisition 
Management, Administrative Operations Service, 
Program Support Center, Rockville, Maryland. 

Niyati Pandya, M.S., M.Phil., M.L.S., Reference 
Librarian, R.O.W. Sciences, Inc., Rockville, 
Maryland. 



Charlotte Gordon, Public Affairs Specialist, Office of 
the Director, Center for Mental Health Services, 
Substance Abuse and Mental Health Services 
Administration, Rockville, Maryland. 

Beatriz Gramley, Public Health Analyst, Primary Care 
Services Branch, Division of Community Based 
Programs, HIV/AIDS Bureau, Health Resources and 
Services Administration, Rockville, Maryland. 



Theodora Radcliffe, Technical Writer/Editor, R.O.W. 
Sciences, Inc., Rockville, Maryland. 

Sanjeev Rana, M.S., Research Assistant, R.O.W. 
Sciences, Inc., Rockville, Maryland. 

Lisa Robbins, Wordprocessing & Desktopping 
Coordinator. R.O.W. Sciences, Inc., Rockville, 
Maryland. 



CAPT G. Bryan Jones, Ph.D., Emergency Coordin- 
ator, Public Health Service Region Three- 
Philadelphia, Office of Emergency Preparedness, 
Office of Public Health and Science, Office of the 
Secretary, Philadelphia, Pennsylvania. 



Doreen Major Ryan, M.A., Writer/Editor, R.O.W. 
Sciences, Inc., Rockville, Maryland. 

Sally Sieracki, M.A., Editor, R.O.W. Sciences, Inc., 
Rockville, Maryland, 



Walter Leginski, Ph.D., Branch Chief, Homeless 
Programs Branch, Division of Knowledge 
Development and Systems Change, Center for Mental 
Health Services, Substance Abuse and Mental Health 
Services Administration, Rockville, Maryland. 

Ken Lostoski, Senior Graphic Designer, R.O.W. 
Sciences, Inc., Rockville, Maryland. 



Damon Thompson, Director of Communications, 
Office of Public Health and Science, Office of the 
Assistant Secretary, Washington, D.C. 

Robin Toliver, Senior Conference Planner, BL 
Seamon and Associates, Inc., Lanham, Maryland. 

Joanna Tyler, Ph.D., Project Director, R.O.W. 
Sciences, Inc., Rockville, Maryland. 



XV 



Mental Health: A Report of the Surgeon General 



Mark Weber, Associate Administrator, Office of 
Communications, Substance Abuse and Mental 
Health Services Administration, Rockville, Maryland. 

Clarissa Wittenberg, Director, Office of Scientific 
Information, National Institute of Mental Health, 
National Institutes of Health, Bethesda, Maryland. 

Baldwin Wong, Program Analyst, Office of Science 
Policy, Analysis, and Communication, National 
Institute of Child Health and Human Development, 
National Institutes of Health, Bethesda, Maryland. 

Special Thanks To 
Organizations 

The Carter Center, Atlanta, Georgia. 

The John D. and Catherine T. MacArthur Foundation, 
Chicago, Illinois. 

Individuals 

Virginia Shankle Bales, M.P.H., Deputy Director for 
Program Management, Centers for Disease Control 
and Prevention, Atlanta, Georgia. 

Byron Breedlove, M.A., Senior Writer/Editor, 
Technical Information and Editorial Services Branch, 
National Center for Chronic Disease Prevention and 
Health Promotion, Centers for Disease Control and 
Prevention, Atlanta, Georgia. 

Thomas Bryant, M.D., J.D., Chairman, Non-Profit 
Management Associates, Inc., Washington, DC. 

Rosalynn Cjirter, Vice Chair, The Carter Center, 
Atlanta, Georgia. 

RADM J. Jarrett Clinton, M.D., Regional Health 
Administrator, Office of the Secretary, Atlanta, 
Georgia. 



Michael P. Eriksen, Sc.D., Director, Office on 
Smoking and Health, National Center for Chronic 
Disease Prevention and Health Promotion, Centers for 
Disease Control and Prevention, Atlanta, Georgia. 

Christine S. Fralish, M.L.I.S., Chief, Technical 
Information and Editorial Services Branch, National 
Center for Chronic Disease Prevention and Health 
Promotion, Centers for Disease Control and 
Prevention, Atlanta, Georgia. 

Adele Franks, M.D., Prudential Center for Health 
Services Research (formerly Assistant Director for 
Science, National Center for Chronic Disease 
Prevention and Health Promotion, Centers for Disease 
Control and Prevention), Atlanta, Georgia. 

RADM Retired Peter Frommer, M.D., Deputy 
Director Emeritus, National Heart, Lung, and Blood 
Institute, National Institutes of Health, Bethesda, 

Maryland. 

Gayle Lloyd, M.A., Managing Editor, Surgeon 
General Reports, Office on Smoking and Health, 
National Center for Chronic Disease Prevention and 
Health Promotion, Centers for Disease Control and 
Prevention, Atlanta, Georgia. 

Sandra P. Perlmutter, Executive Director, President's 
Council on Physical Fitness and Sports, Washington, 
D.C. 



NOTICE 



The editor, the contributors, and the 
publisher are grateful to the American 
Psychiatric Association for permission to 
quote directly from Diagnostic and Statistical 
Manual of Mental Disorders (DSM-IV), 4th 
ed. in this work. Descriptive matter is 
enclosed in quotation marks in the text 
exactly as it appears in DSM-IV. Tabular 
matter is modified slightly as to form only in 
accordance with the publisher's editorial 
usage. 



XVI 



Mental Health: 



A Report of the Surgeon General 



Chapter 1 : Introduction and Themes 1 

Overarching Themes 3 

The Science Base of the Report 9 

Overview of the Report's Chapters 11 

Chapter Conclusions 13 

Preparation of the Report 23 

References 24 

Chapter 2: The Fundamentals of Mental Health and Mental Illness 27 

The Neuroscience of Mental Health 32 

Overview of Mental Illness 39 

Overview of Etiology 49 

Overview of Development, Temperament, and Risk Factors 57 

Overview of Prevention 62 

Overview of Treatment 64 

Overview of Mental Health Services 73 

Overview of Cultural Diversity and Mental Health Services 80 

Overview of Consumer and Family Movements 92 

Overview of Recovery 97 

Conclusions 100 

References 104 

Chapter 3: Children and Mental Health 117 

Normal Development 124 

Overview of Risk Factors and Prevention 129 

Overview of Mental Disorders in Children 136 

Attention-Deficit/Hyperactivity Disorder 142 

Depression and Suicide in Children and Adolescents 150 

Other Mental Disorders in Children and Adolescents 160 

Services Interventions 168 

Service Delivery 179 

Conclusions 193 

References 194 



A Report of the Surgeon General 



Chapter 4: Adults and Mental Health 221 

Chapter Overview 225 

Anxiety Disorders 233 

Mood Disorders 244 

Schizophrenia 269 

Service Delivery 285 

Other Services And Supports 289 

Conclusions 296 

References 296 

Chapter 5: Older Adults and Mental Health 331 

Chapter Overview 336 

Overview of Mental Disorders in Older Adults 340 

Depression in Older Adults 346 

Alzheimer's Disease 356 

Other Mental Disorders in Older Adults 364 

Service Delivery 370 

Other Services and Supports 378 

Conclusions 381 

References 381 

Chapter 6: Organizing and Financing Mental Health Services 403 

Overview of the Current Service System 405 

The Costs of Mental Illness 411 

Financing and Managing Mental Health Care 418 

Toward Parity in Coverage of Mental Health Care 426 

Conclusions 428 

Appendix 6-A: Quality and Consumers' Rights 430 

References 430 

Chapter 7: Confidentiality of Mental Health Information 435 

Chapter Overview 438 

Ethical Issues About ConfidentiaHty 438 

Values Underlying Confidentiality 439 

Research on ConfidentiaHty and Mental Health Treatment 440 

Current State of Confidentiality Law 441 

Federal Confidentiality Laws 446 

Potential Problems With the Current Legal Framework 447 

Summary 448 

Conclusions 449 

References 449 



Mental Health 

Chapter 8: A Vision for the Future 45 1 

Continue To Build the Science Base 453 

Overcome Stigma 454 

Improve Public Awareness of Effective Treatment 454 

Ensure the Supply of Mental Health Services and Providers 455 

Ensure Delivery of State-of-the-Art Treatments 455 

Tailor Treatment to Age, Gender, Race, and Culture 456 

Facilitate Entry Into Treatment 457 

Reduce Financial Barriers to Treatment 457 

Conclusion 458 

References 458 

Appendix: Directory of Resources 459 

List of Tables and Figures 463 

Index 467 



Chapter 1 
Introduction and Themes 



Contents 



Overarching Themes 3 

Mental Health and Mental Illness: A Public Health Approach 3 

Mental Disorders are Disabling 4 

Mental Health and Mental Dlness: Points on a Continuum 4 

Mind and Body are Inseparable 5 

The Roots of Stigma 6 

Separation of Treatment Systems 6 

Public Attitudes About Mental Illness: 1950s to 1990s 7 

Stigma and Seeking Help for Mental Disorders 8 

Stigma and Paying for Mental Disorder Treatment 8 

Reducing Stigma 8 

The Science Base of the Report 9 

Reliance on Scientific Evidence 9 

Research Methods 10 

Levels of Evidence 10 

Overview of the Report's Chapters 11 

Chapter Conclusions 13 

Chapter 2: The Fundamentals of Mental Health and Mental Illness 13 

Chapter 3: Children and Mental Health 17 

Chapter 4: Adults and Mental Health 18 

Chapter 5: Older Adults and Mental Health 19 

Chapter 6: Organization and Financing of Mental Health Services 19 

Chapter 7: Confidentiality of Mental Health Information: Ethical, Legal, and Policy Issues . . 20 

Chapter 8: A Vision for the Future — Actions for Mental Health in the New Millennium .... 21 

Preparation of the Report 23 

References 24 



Chapter 1 

Introduction and Themes 



'T'his first Surgeon General's Report on Mental 
Health is issued at the culmination of a half-century 
that has witnessed remarkable advances in the 
understanding of mental disorders and the brain and in 
our appreciation of the centrality of mental health to 
overall health and well-being. The report was prepared 
against a backdrop of growing awareness in the United 
States and throughout the world of the immense burden 
of disability associated with mental illnesses. In the 
United States, mental disorders collectively account for 
more than 15 percent of the overall burden of disease 
from all causes and slightly more than the burden 
associated with all forms of cancer (Murray & Lopez, 
1996). These data underscore the importance and 
urgency of treating and preventing mental disorders and 
of promoting mental health in our society. 

The report in its entirety provides an up-to-date 
review of scientific advances in the study of mental 
health and of mental illnesses that affect at least one in 
five Americans. Several important conclusions may be 
drawn from the extensive scientific literature 
summarized in the report. One is that a variety of 
treatments of well-documented efficacy exist for the 
array of clearly defined mental and behavioral 
disorders that occur across the life span. Every person 
should be encouraged to seek help when questions arise 
about mental health, just as each person is encouraged 
to seek help when questions arise about health. 
Research highlighted in the report demonstrates that 
mental health is a facet of health that evolves 
throughout the lifetime. Just as each person can do 
much to promote and maintain overall health regardless 
of age, each also can do much to promote and 
strengthen mental health at every stage of life. 

Much remains to be learned about the causes, 
treatment, and prevention of mental and behavioral 



disorders. Obstacles that may limit the availability or 
accessibility of mental health services for some 
Americans are being dismantled, but disparities persist. 
Still, thanks to research and the experiences of millions 
of individuals who have a mental disorder, their family 
members, and other advocates, the Nation has the 
power today to tear down the most formidable obstacle 
to future progress in the arena of mental illness and 
health. That obstacle is stigma. Stigmatization of 
mental illness is an excuse for inaction and 
discrimination that is inexcusably outmoded in 1999. 
As evident in the chapters that follow, we have 
acquired an immense amount of knowledge that permits 
us, as a Nation, to respond to the needs of persons with 
mental illness in a manner that is both effective and 
respectful. 

Overarching Themes 

Mental Health and Mental Illness: A Public 
Health Approach 

The Nation's contemporary mental health enterprise, 
like the broader field of health, is rooted in a 
population-based public health model. The public 
health model is characterized by concern for the health 
of a population in its entirety and by awareness of the 
linkage between health and the physical and psycho- 
social environment. Public health focuses not only on 
traditional areas of diagnosis, treatment, and etiology, 
but also on epidemiologic surveillance of the health of 
the population at large, health promotion, disease pre- 
vention, and access to and evaluation of services (Last 
& Wallace, 1992). 

Just as the mainstream of public health takes a 
broad view of health and illness, this Surgeon 
General's Report on Mental Health takes a wide-angle 
lens to both mental health and mental illness. In years 



Mental Health: A Report of the Surgeon General 



past, the mental health field often focused principally 
on mental illness in order to serve individuals who 
were most severely affected. Only as the field has 
matured has it begun to respond to intensifying interest 
and concerns about disease prevention and health pro- 
motion. Because of the more recent consideration of 
these topic areas, the body of accumulated knowledge 
regarding them is not as expansive as that for mental 
illness. 

Mental Disorders are Disabling 

The burden of mental illness on health and productivity 
in the United States and throughout the world has long 
been profoundly underestimated. Data developed by the 
massive Global Burden of Disease study,' conducted by 
the World Health Organization, the World Bank, and 
Harvard University, reveal that mental illness, 
including suicide,^ ranks second in the burden of 
disease in established market economies, such as the 
United States (Table 1-1). 

Mental illness emerged from the Global Burden of 
Disease study as a surprisingly significant contributor 
to the burden of disease. The measure of calculating 
disease burden in this study, called Disability Adjusted 
Life Years (DALYs), allows comparison of the burden 

Table 1-1. Disease burden by selected illness 
categories in established market 
economies, 1990 



Percent of 
Total DALYs* 


All cardiovascular conditions 


18.6 


All mental illness** 


15.4 


All malignant diseases (cancer) 


15.0 


All respiratory conditions 


4.8 


All alcohol use 


4.7 


All infectious and parasitic diseases 


2.8 


All drug use 


1.5 



*Disability-adjusted life year (DALY) is a measure that 

expresses years of life lost to premature death and years 

lived with a disability of specified severity and duration 

(Murray & Lopez, 1996). 

**Disease burden associated with "mental illness" includes 

suicide. 



' Murray & Lopez, 1996. 

^ The Surgeon General issued a Call to Action on Suicide in 1999, 
reflecting the public health magnitude of this consequence of mental 
illness. The Call to Action is summarized in Figure 4-1. 



of disease across many different disease conditions. 
DALYs account for lost years of healthy life regardless 
of whether the years were lost to premature death or 
disability. The disability component of this measure is 
weighted for severity of the disability. For example, 
major depression is equivalent in burden to blindness 
or paraplegia, whereas active psychosis seen in 
schizophrenia is equal in disability burden to 
quadriplegia. 

By this measure, major depression alone ranked 
second only to ischemic heart disease in magnitude of 
disease burden (see Table 1-2). Schizophrenia, bipolar 
disorder, obsessive-compulsive disorder, panic 
disorder, and post-traumatic stress disorder also 
contributed significantly to the burden represented by 
mental illness. 

Table 1-2. Leading sources of disease burden in 
established market economies, 1990 







Total 

DALYs 

(millions) 


Percent 
of Total 




All causes 


98.7 




1 


Ischemic heart disease 


8.9 


9.0 


2 


Unipolar major depression 


6.7 


6.8 


3 


Cardiovascular disease 


5.0 


5.0 


4 


Alcohol use 


4.7 


4.7 


5 


Road traffic accidents 


4.3 


4.4 



Source: Murray & Lopez, 1996. 

Mental Health and Mental Illness: Points on 
a Continuum 

As will be evident in the pages that follow, "mental 
health" and "mental illness" are not polar opposites but 
may be thought of as points on a continuum. Mental 
health is a state of successful performance of mental 
function, resulting in productive activities, fulfilling 
relationships with other people, and the ability to adapt 
to change and to cope with adversity. Mental health is 
indispensable to personal well-being, family and 
interpersonal relationships, and contribution to 
community or society. It is easy to overlook the value 
of mental health until problems surface. Yet from early 
childhood until death, mental health is the springboard 
of thinking and communication skills, learning, 
emotional growth, resilience, and self-esteem. These 



Introduction and Themes 



are the ingredients of each individual's successful 
contribution to community and society. Americans are 
inundated with messages about success — in school, in 
a profession, in parenting, in relationships — without 
appreciating that successful performance rests on a 
foundation of mental health. 

Many ingredients of mental health may be 
identifiable, but mental health is not easy to define. In 
the words of a distinguished leader in the field of 
mental health prevention, ". . . built into any definition 
of wellness ... are overt and covert expressions of 
values. Because values differ across cultures as well as 
among subgroups (and indeed individuals) within a 
culture, the ideal of a uniformly acceptable definition 
of the constructs is illusory" (Cowen, 1994). In other 
words, what it means to be mentally healthy is subject 
to many different interpretations that are rooted in 
value judgments that may vary across cultures. The 
challenge of defining mental health has stalled the 
development of programs to foster mental health 
(Seeker, 1998), although strides have been made with 
wellness programs for older people (Chapter 5). 

Mental illness is the term that refers collectively to 
all diagnosable mental disorders. Mental disorders are 
health conditions that are characterized by alterations 
in thinking, mood, or behavior (or some combination 
thereof) associated with distress and/or impaired 
functioning. Alzheimer' s disease exemplifies a mental 
disorder largely marked by alterations in thinking 
(especially forgetting). Depression exemplifies a 
mental disorder largely marked by alterations in mood. 
Attention-deficit/hyperactivity disorder exemplifies a 
mental disorder largely marked by alterations in 
behavior (overactivity) and/or thinking (inability to 
concentrate). Alterations in thinking, mood, or behavior 
contribute to a host of problems — patient distress, 
impaired functioning, or heightened risk of death, pain, 
disability, or loss of freedom (American Psychiatric 
Association, 1994). 

This report uses the term "mental health problems" 
for signs and symptoms of insufficient intensity or 
duration to meet the criteria for any mental disorder. 
Almost everyone has experienced mental health 
problems in which the distress one feels matches some 



of the signs and symptoms of mental disorders. Mental 
health problems may warrant active efforts in health 
promotion, prevention, and treatment. Bereavement 
symptoms in older adults offer a case in point. 
Bereavement symptoms of less than 2 months' duration 
do not qualify as a mental disorder, according to 
professional manuals for diagnosis (American 
Psychiatric Association, 1994). Nevertheless, 
bereavement symptoms can be debilitating if they are 
left unattended. They place older people at risk for 
depression, which, in turn, is linked to death from 
suicide, heart attack, or other causes (Zisook & 
Shuchter, 1991, 1993;Frasure-Smithetal., 1993, 1995; 
Con well, 1996). Much can be done — through formal 
treatment or through support group participation — to 
ameliorate the symptoms and to avert the consequences 
of bereavement. In this case, early intervention is 
needed to address a mental health problem before it 
becomes a potentially life-threatening disorder. 

Mind and Body are Inseparable 

Considering health and illness as points along a 
continuum helps one appreciate that neither state exists 
in pure isolation from the other. In another but related 
context, everyday language tends to encourage a 
misperception that "mental health" or "mental illness" 
is unrelated to "physical health" or "physical illness." 
In fact, the two are inseparable. 

Seventeenth-century philosopher Rene Descartes 
conceptualized the distinction between the mind and 
the body. He viewed the "mind" as completely 
separable from the "body" (or "matter" in general). The 
mind (and spirit) was seen as the concern of organized 
religion, whereas the body was seen as the concern of 
physicians (Eisendrath & Feder, in press). This 
partitioning ushered in a separation between so-called 
"mental" and "physical" health, despite advances in the 
20th century that proved the interrelationships between 
mental and physical health (Cohen & Herbert, 1996; 
Baum & Posluszny, 1999). 

Although "mind" is a broad term that has had many 
different meanings over the centuries, today it refers to 
the totality of mental functions related to thinking, 
mood, and purposive behavior. The mind is generally 



Mental Health: A Report of the Surgeon General 



seen as deriving from activities within the brain but 
displaying emergent properties, such as consciousness 
(Fischbach, 1992; Gazzaniga et al, 1998). 

One reason the public continues to this day to 
emphasize the difference between mental and physical 
health is embedded in language. Common parlance 
continues to use the term "physical" to distinguish 
some forms of health and illness from "mental" health 
and illness. People continue to see mental and physical 
as separate functions when, in fact, mental functions 
(e.g., memory) are physical as well (American 
Psychiatric Association, 1994). Mental functions are 
carried out by the brain. Likewise, mental disorders are 
reflected in physical changes in the brain (Kandel, 
1998). Physical changes in the brain often trigger 
physical changes in other parts of the body too. The 
racing heart, dry mouth, and sweaty palms that 
accompany a terrifying nightmare are orchestrated by 
the brain. A nightmare is a mental state associated with 
alterations of brain chemistry that, in turn, provoke 
unmistakable changes elsewhere in the body. 

Instead of dividing physical from mental health, the 
more appropriate and neutral distinction is between 
"mental" and "somatic" health. Somatic is a medical 
term that derives from the Greek word soma for the 
body. Mental health refers to the successful 
performance of mental functions in terms of thought, 
mood, and behavior. Mental disorders are those health 
conditions in which alterations in mental functions are 
paramount. Somatic conditions are those in which 
alterations in nonmental functions predominate. While 
the brain carries out all mental functions, it also carries 
out some somatic functions, such as movement, touch, 
and balance. That is why not all brain diseases are 
mental disorders. For example, a stroke causes a lesion 
in the brain that may produce disturbances of 
movement, such as paralysis of limbs. When such 
symptoms predominate in a patient, the stroke is 
considered a somatic condition. But when a stroke 
mainly produces alterations of thought, mood, or 
behavior, it is considered a mental condition (e.g., 
dementia). The point is that a brain disease can be seen 
as a mental disorder or a somatic disorder depending on 
the functions it perturbs. 



The Roots of Stigma 

Stigmatization of people with mental disorders has 
persisted throughout history. It is manifested by bias, 
distrust, stereotyping, fear, embarrassment, anger, 
and/or avoidance. Stigma leads others to avoid living, 
socializing or working with, renting to, or employing 
people with mental disorders, especially severe 
disorders such as schizophrenia (Penn & Martin, 1998; 
Corrigan & Penn, 1999). It reduces patients' access to 
resources and opportunities (e.g., housing, jobs) and 
leads to low self-esteem, isolation, and hopelessness. It 
deters the public from seeking, and wanting to pay for, 
care. In its most overt and egregious form, stigma 
results in outright discrimination and abuse. More 
tragically, it deprives people of their dignity and 
interferes with their full participation in society. 

Explanations for stigma stem, in part, from the 
misguided split between mind and body first proposed 
by Descartes. Another source of stigma lies in the 19th- 
century separation of the mental health treatment 
system in the United States from the mainstream of 
health. These historical influences exert an often 
immediate influence on perceptions and behaviors in 
the modem world. 

Separation of Treatment Systems 

In colonial times in the United States, people with 
mental illness were described as "lunaticks" and were 
largely cared for by families. There was no concerted 
effort to treat mental illness until urbanization in the 
early 19th century created a societal problem that 
previously had been relegated to families scattered 
among small rural communities. Social policy assumed 
the form of isolated asylums where persons with mental 
illness were administered the reigning treatments of the 
era. By the late 19th century, mental illness was 
thought to grow "out of a violation of those physical, 
mental and moral laws which, properly understood and 
obeyed, result not only in the highest development of 
the race, but the highest type of civilization" (cited in 
Grob, 1983). Throughout the history of 
institutionalization in asylums (later renamed mental 
hospitals), reformers strove to improve treatment and 
curtail abuse. Several waves of reform culminated in 



Introduction and Themes 



the deinstitutionalization movement that began in the 
1950s with the goal of shifting patients and care to the 
community. 

Public Attitudes About Mental Illness: 1950s to 
1990s 

Nationally representative surveys have tracked public 
attitudes about mental illness since the 1950s (Star, 
1952, 1955;Gurinetal., 1960; Veroff et al, 1981). To 
permit comparisons over time, several surveys of the 
1970s and the 1990s phrased questions exactly as they 
had been asked in the 1950s (Swindle et al., 1997). 

In the 1950s, the public viewed mental illness as a 
stigmatized condition and displayed an unscientific 
understanding of mental illness. Survey respondents 
typically were not able to identify individuals as 
"mentally ill" when presented with vignettes of 
individuals who would have been said to be mentally ill 
according to the professional standards of the day. The 
public was not particularly skilled at distinguishing 
mental illness from ordinary unhappiness and worry 
and tended to see only extreme forms of be- 
havior — namely psychosis — as mental illness. Mental 
illness carried great social stigma, especially linked 
with fear of unpredictable and violent behavior (Star, 
1952, 1955; Gurin et al, 1960; Veroff et al., 1981). 

By 1996, a modem survey revealed that Americans 
had achieved greater scientific understanding of mental 
illness. But the increases in knowledge did not defuse 
social stigma (Phelan et al., 1997). The public learned 
to define mental illness and to distinguish it from 
ordinary worry and unhappiness. It expanded its 
definition of mental illness to encompass anxiety, 
depression, and other mental disorders. The public 
attributed mental illness to a mix of biological 
abnormalities and vulnerabilities to social and 
psychological stress (Link et al., in press). Yet, in 
comparison with the 1950s, the public's perception of 
mental illness more frequently incorporated violent 
behavior (Phelan et al., 1997). This was primarily true 
among those who defined mental illness to include 
psychosis (a view held by about one-third of the entire 
sample). Thirty-one percent of this group mentioned 
violence in its descriptions of mental illness, in 



comparison with 13 percent in the 1950s. In other 
words, the perception of people with psychosis as being 
dangerous is stronger today than in the past (Phelan et 
al., 1997). 

The 1996 survey also probed how perceptions of 
those with mental illness varied by diagnosis. The 
public was more likely to consider an individual with 
schizophrenia as having mental illness than an 
individual with depression. All of them were 
distinguished reasonably well from a worried and 
unhappy individual who did not meet professional 
criteria for a mental disorder. The desire for social 
distance was consistent with this hierarchy (Link et al., 
in press). 

Why is stigma so strong despite better public 
understanding of mental illness? The answer appears 
to be fear of violence: people with mental illness, 
especially those with psychosis, are perceived to be 
more violent than in the past (Phelan et al., 1997). 

This finding begs yet another question: Are people 
with mental disorders truly more violent? Research 
supports some public concerns, but the overall 
likelihood of violence is low. The greatest risk of 
violence is from those who have dual diagnoses, i.e., 
individuals who have a mental disorder as well as a 
substance abuse disorder (Swanson, 1994; Kronen et 
al, 1998; Steadman et al., 1998). There is a small 
elevation in risk of violence from individuals with 
severe mental disorders (e.g., psychosis), especially if 
they are noncompliant with their medication (Kronen et 
al., 1998; Swartz et al., 1998). Yet the risk of violence 
is much less for a stranger than for a family member or 
person who is known to the person with mxCntal illness 
(Kronen et al., 1998). In fact, there is very little risk of 
violence or harm to a stranger from casual contact 
with an individual who has a mental disorder. Because 
the average person is ill-equipped to judge whether 
someone who is behaving erratically has any of these 
disorders, alone or in combination, the natural tendency 
is to be wary. Yet, to put this all in perspective, the 
overall contribution of mental disorders to the total 
level of violence in society is exceptionally small 
(Swanson, 1994). 



Mental Health: A Report of the Surgeon General 



Because most people should have little reason to 
fear violence from those with mental illness, even in its 
most severe forms, why is fear of violence so 
entrenched? Most speculations focus on media 
coverage and deinstitutionaUzation(Phelanetal., 1997; 
Heginbotham, 1998). One series of surveys found that 
selective media reporting reinforced the public's 
stereotypes linking violence and mental illness and 
encouraged people to distance themselves from those 
with mental disorders (Angermeyer & Matschinger, 
1996). And yet, deinstitutionalization made this 
distancing impossible over the 40 years as the 
population of state and county mental hospitals was 
reduced from a high of about 560,000 in 1955 to well 
below 100,000 by the 1990s (Bachrach, 1996). Some 
advocates of deinstitutionalization expected stigma to 
be reduced with community care and commonplace 
exposure. Stigma might have been greater today had 
not public education resulted in a more scientific 
understanding of mental illness. 

Stigma and Seeking Help for Mental Disorders 

Nearly two-thirds of all people with diagnosable mental 
disorders do not seek treatment (Regier et al., 1993; 
Kessler et al., 1996). Stigma surrounding the receipt of 
mental health treatment is among the many barriers that 
discourage people from seeking treatment (Sussman et 
al., 1987; Cooper-Patrick et al., 1997). Concern about 
stigma appears to be heightened in rural areas in 
relation to larger towns or cities (Hoyt et al., 1997). 
Stigma also disproportionately affects certain age 
groups, as explained in the chapters on children and 
older people. 

The surveys cited above concerning evolving 
public attitudes about mental illness also monitored 
how people would cope with, and seek treatment for, 
mental illness if they became symptomatic. (The term 
"nervous breakdown" was used in lieu of the term 
"mental illness" in the 1996 survey to allow for 
comparisons with the surveys in the 1950s and 1970s.) 
The 1996 survey found that people were likelier than in 
the past to approach mental illness by coping with, 
rather than by avoiding, the problem. They also were 
more likely now to want informal social supports (e.g., 



self-help groups). Those who now sought formal 
support increasingly preferred counselors, 
psychologists, and social workers (Swindle et al., 
1997). 

Stigma and Paying for Mental Disorder Treatment 

Another manifestation of stigma is reflected in the 
public's reluctance to pay for mental health services. 
Public willingness to pay for mental health treatment, 
particularly through insurance premiums or taxes, has 
been assessed largely through public opinion polls. 
Members of the public report a greater willingness to 
pay for insurance coverage for individuals with severe 
mental disorders, such as schizophrenia and depression, 
rather than for less severe conditions such as worry and 
unhappiness (Hanson, 1998). While the public 
generally appears to support paying for treatment, its 
support diminishes upon the realization that higher 
taxes or premiums would be necessary (Hanson, 1998). 
In the lexicon of survey research, the willingness to pay 
for mental illness treatment services is considered to be 
"soft." The public generally ranks insurance coverage 
for mental disorders below that for somatic disorders 
(Hanson, 1998). 

Reducing Stigma 

There is likely no simple or single panacea to eliminate 
the stigma associated with mental illness. Stigma was 
expected to abate with increased knowledge of mental 
illness, but just the opposite occurred: stigma in some 
ways intensified over the past 40 years even though 
understanding improved. Knowledge of mental illness 
appears by itself insufficient to dispel stigma (Phelan et 
al., 1997). Broader knowledge may be warranted, 
especially to redress public fears (Penn & Martin, 
1998). Research is beginning to demonstrate that 
negative perceptions about severe mental illness can be 
lowered by furnishing empirically based information on 
the association between violence and severe mental 
illness (Penn & Martin, 1998). Overall approaches to 
stigma reduction involve programs of advocacy, public 
education, and contact with persons with mental illness 
through schools and other societal institutions 
(Corrigan & Penn, 1999). 



Introduction and Themes 



Another way to eliminate stigma is to find causes 
and effective treatments for mental disorders (Jones, 
1998). History suggests this to be true. Neurosyphilis 
and pellagra are illustrative of mental disorders for 
which stigma has receded. In the early part of this 
century, about 20 percent of those admitted to mental 
hospitals had "general paresis," later identified as 
tertiary syphilis (Grob, 1994). This advanced stage of 
syphilis occurs when the bacterium invades the brain 
and causes neurological deterioration (including 
psychosis), paralysis, and death. The discoveries of an 
infectious etiology and of penicillin led to the virtual 
elimination of neurosyphilis. Similarly, when pellagra 
was traced to a nutrient deficiency, and nutritional 
supplementation with niacin was introduced, the 
condition was eventually eradicated in the developed 
world. Pellagra' s victims with delirium had been placed 
in mental hospitals early in the 20th century before its 
etiology was clarified. Although no one has 
documented directly the reduction of public stigma 
toward these conditions over the early and later parts of 
this century, disease eradication through widespread 
acceptance of treatment (and its cost) offers indirect 
proof. 

Ironically, these examples also illustrate a more 
unsettling consequence: that the mental health field was 
adversely affected when causes and treatments were 
identified. As advances were achieved, each condition 
was transferred from the mental health field to another 
medical specialty (Grob, 1 99 1 ). For instance, dominion 
over syphilis was moved to dermatology, internal 
medicine, and neurology upon advances in etiology and 
treatment. Dominion over hormone-related mental 
disorders was moved to endocrinology under similar 
circumstances. The consequence of this transformation, 
according to historian Gerald Grob, is that the mental 
health field became over the years the repository for 
mental disorders whose etiology was unknown. This 
left the mental health field "vulnerable to accusations 
by their medical brethren that psychiatry was not part 
of medicine, and that psychiatric practice rested on 
superstition and myth" (Grob, 1991). 

These historical examples signify that stigma 
dissipates for individual disorders once advances 



render them less disabling, infectious, or disfiguring. 
Yet the stigma surrounding other mental disorders not 
only persists but may be inadvertently reinforced by 
leaving to mental health care only those behavioral 
conditions without known causes or cures. To point this 
out is not intended to imply that advances in mental 
health should be halted; rather, advances should be 
nurtured and heralded. The purpose here is to explain 
some of the historical origins of the chasm between the 
health and mental health fields. 

Stigma must be overcome. Research that will 
continue to yield increasingly effective treatments for 
mental disorders promises to be an effective antidote. 
When people understand that mental disorders are not 
the result of moral failings or limited will power, but 
are legitimate illnesses that are responsive to specific 
treatments, much of the negative stereotyping may 
dissipate. Still, fresh approaches to disseminate 
research information and, thus, to counter stigma need 
to be developed and evaluated. Social science research 
has much to contribute to the development and 
evaluation of anti-stigma programs (Corrigan & Penn, 
1999). As stigma abates, a transformation in public 
attitudes should occur. People should become eager to 
seek care. They should become more wiUing to absorb 
its cost. And, most importantly, they should become far 
more receptive to the messages that are the subtext of 
this report: mental health and mental illness are part of 
the mainstream of health, and they are a concern for all 
people. 

The Science Base of the Report 

Reliance on Scientific Evidence 

The statements and conclusions throughout this report 
are documented by reference to studies published in the 
scientific literature. For the most part, this report cites 
studies of empirical — rather than theoretical — research, 
peer-reviewed journal articles including reviews that 
integrate findings from numerous studies, and books by 
recognized experts. When a study has been accepted for 
publication but the publication has not yet appeared, 
owing to the delay between acceptance and final 
publication, the study is referred to as "in press." The 



Mental Health: A Report of the Surgeon General 



report refers, on occasion, to unpublished research by 
means of reference to a presentation at a professional 
meeting or to a "personal communication" from the 
researcher, a practice that also is used sparingly in 
professional journals. These personal references are to 
acknowledged experts whose research is in progress. 

Research Methods 

Quality research rests on accepted methods of testing 
hypotheses. Two of the more common research 
methods used in the mental health field are 
experimental research and correlational research. 
Experimental research is the preferred method for 
assessing causation but may be too difficult or too 
expensive to conduct. Experimental research strives to 
discover cause and effect relationships, such as whether 
a new drug is effective for treating a mental disorder, hi 
an experimental study, the investigator deliberately 
introduces an intervention to determine its conse- 
quences (i.e., the drug's efficacy). The investigator sets 
up an experiment comparing the effects of giving the 
new drug to one group of people, the experimental 
group, while giving a placebo (an inert pill) to another 
group, the so-called control group. The incorporation of 
a control group rules out the possibility that something 
other than the experimental treatment (i.e., the new 
drug) produces the results. The difference in outcome 
between the experimental and control group — which, 
in this case, may be the reduction or ehmination of the 
symptoms of the disorder — then can be causally 
attributed to the drug. Similarly, in an experimental 
study of a psychological treatment, the experimental 
group is given a new type of psychotherapy, while the 
control or comparison group receives either no 
psychotherapy or a different form of psychotherapy. 
With both pharmacological and psychological studies, 
the best way to assign study participants, called 
subjects, either to the treatment or the control (or 
comparison) group is by assigning them randomly to 
different treatment groups. Randomization reduces bias 
in the results. An experimental study in humans with 
randomization is called a randomized controlled trial. 
Correlational research is employed when 
experimental research is logistically, ethically, or 



financially impossible. Instead of deliberately 
introducing an intervention, researchers observe 
relationships to uncover whether two factors are 
associated, or correlated. Studying the relationship 
between stress and depression is illustrative. It would 
be unthinkable to introduce seriously stressful events to 
see if they cause depression. A correlational study in 
this case would compare a group of people already 
experiencing high levels of stress with another group 
experiencing low levels of stress to determine whether 
the high-stress group is more likely to develop 
depression. If this happens, then the results would 
indicate that high levels of stress are associated with 
depression. The limitation of this type of study is that 
it only can be used to establish associations, not cause 
and effect relationships. (The positive relationship 
between stress and depression is discussed most 
thoroughly in Chapter 4.) 

Controlled studies — that is, studies with control or 
comparison groups — are considered superior to 
uncontrolled studies. But not every question in mental 
health can be studied with a control or comparison 
group. Findings from an uncontrolled study may be 
better than no information at all. An uncontrolled study 
also may be beneficial in generating hypotheses or in 
testing the feasibility of an intervention. The results 
presumably would lead to a controlled study. In short, 
uncontrolled studies offer a good starting point but are 
never conclusive by themselves. 

Levels of Evidence 

In science, no single study by itself, however well 
designed, is generally considered sufficient to establish 
causation. The findings need to be replicated by other 
investigators to gain widespread acceptance by the 
scientific community. 

The strength of the evidence amassed for any 
scientific fact or conclusion is referred to as "the level 
of evidence." The level of evidence, for example, to 
justify the entry of a new drug into the marketplace has 
to be substantial enough to meet with approval by the 
U.S. Food and Drug Administration (FDA). According 
to U.S. drug law, a new drug's safety and efficacy must 
be established through controlled clinical trials 



10 



Introduction and Themes 



conducted by the drug's manufacturer or sponsor 
(FDA, 1998). The FDA's decision to approve a drug 
represents the culmination of a lengthy, research- 
intensive process of drug development, which often 
consumes years of animal testing followed by human 
clinical trials (DiMasi & Lasagna, 1995). The FDA 
requires three phases of clinical trials^ before a new 
drug can be approved for marketing (FDA, 1998). 

With psychotherapy, the level of evidence similarly 
must be high. Although there are no formal Federal 
laws governing which psychotherapies can be 
introduced into practice, professional groups and 
experts in the field strive to assess the level of evidence 
in a given area through task forces, review articles, and 
other methods for evaluating the body of published 
studies on a topic. This Surgeon General's report is 
replete with references to such evaluations. One of the 
most prominent series of evaluations was set in motion 
by a group within the American Psychological 
Association (APA), one of the main professional 
organizations of psychologists. Beginning in the mid- 
1990s, the APA's Division of Clinical Psychology 
convened task forces with the objective of establishing 
which psychotherapies were of proven efficacy. To 
guide their evaluation, the first task force created a set 
of criteria that also was used or adapted by subsequent 
task forces. The first task force actually developed two 
sets of criteria: the first, and more rigorous, set of 
criteria was for Weil-Established Treatments, while the 
other set was for Probably Efficacious Treatments 
(Chambless et al, 1996). For a psychotherapy to be 
well established, at least two experiments with group 
designs or similar types of studies must have been 
published to demonstrate efficacy. Chapters 3 through 
5 of this report describe the findings of the task forces 
in relation to psychotherapies for children, adults, and 
older adults. Some types of psychotherapies that do not 
meet the criteria might be effective but may not have 
been studied sufficiently. 



^ The first phase is to establish safety (Phase I), while the latter two 
phases establish efficacy through small and then large-scale 
randomized controlled clinical trials (Phases II and III) (FDA, 
1998). 



Another way of evaluating a collection of studies 
is through a formal statistical technique called a meta- 
analysis. A meta-analysis is a way of combining results 
from multiple studies. Its goal is to determine the size 
and consistency of the "effect" of a particular treatment 
or other intervention observed across the studies. The 
statistical technique makes the results of different 
studies comparable so that an overall "effect size" for 
the treatment can be identified. A meta-analysis 
determines if there is consistent evidence of a 
statistically significant effect of a specified treatment 
and estimates the size of the effect, according to widely 
accepted standards for a small, medium, or large effect. 

Overview of the Report's Chapters 

The preceding sections have addressed overarching 
themes in the body of the report. This section provides 
a brief overview of the entire report, including a 
description of its general orientation and a summary of 
key conclusions drawn from each chapter. 

Chapter 2 begins with an overview of research 
under way today that is focused on the brain and 
behavior in mental health and mental illness. It explains 
how newer approaches to neuroscience are mending the 
mind-body split, which for so long has been a 
stumbling block to understanding the relationship of 
the brain to behavior, thought, and emotion. Modem 
integrative neuroscience offers a means of linking 
research on broad "systems-level" aspects of brain 
function with the remarkably detailed tools and 
findings of molecular genetics. There follows an 
overview of mental illness that highlights topics 
including symptoms, diagnosis, epidemiology (i.e., 
research having to do with the distribution and 
determinants of mental disorders in population groups), 
and cost, all of which are discussed in the context of 
specific disorders throughout the report. The section on 
etiology reviews research that is seeking to define, with 
ever greater precision, the causes of mental illnesses. 
As will be seen, etiology research must examine 
fundamental biological and behavioral processes, as 
well as a necessarily broad array of life events. No less 
than research on normal healthy development, 
etiological research underscores the inextricability of 



11 



Mental Health: A Report of the Surgeon General 



nature and nurture, or biological and psychosocial 
influences, in mental illness. The section on 
development of temperament reveals how mental health 
research has attempted over much of the past century to 
understand how biological, psychological, and 
sociocultural factors meld in health as well as illness. 
The chapter then reviews research approaches to the 
prevention and treatment of mental disorders and 
provides an overview of mental health services and 
their delivery. Final sections cover the growing 
influence on the mental health field of cultural 
diversity, the importance of consumerism, and new 
optimism about recovery from mental illness. 

Chapters 3, 4, and 5 capture the breadth, depth, and 
vibrancy of the mental health field. The chapters probe 
mental health and mental illness in children and 
adolescents, in adulthood (i.e., in persons up to ages 55 
to 65), and in older adults, respectively. This life span 
approach reflects awareness that mental health, and the 
brain and behavioral disorders that impinge upon it, are 
dynamic, ever-changing phenomena that, at any given 
moment, reflect the sum total of every person's genetic 
inheritance and life experiences. The brain is 
extraordinarily "plastic," or malleable. It interacts with 
and responds — both in its function and in its very 
structure— to multiple influences continuously, across 
every stage of life. Variability in expression of mental 
health and mental illness over the life span can be very 
subtle or very pronounced. As an example, the 
symptoms of separation anxiety are normal in early 
childhood but are signs of distress in later childhood 
and beyond. It is all too common for people to 
appreciate the impact of developmental processes in 
children yet not to extend that conceptual 
understanding to older people. In fact, older people 
continue to develop and change. Different stages of Hfe 
are associated with distinct forms of mental and 
behavioral disorders and with distinctive capacities for 
mental health. 

With rare exceptions, few persons are destined to 
a life marked by unremitting, acute mental illness. The 
most severe, persistent forms of mental illness tend to 
be amenable to treatment, even when recurrent and 
episodic. As conditions wax and wane, opportunities 



exist for interventions. The goal of an intervention at 
any given time may vary. The focus may be on 
recovery, prevention of recurrence, or the acquisition of 
knowledge or skills that permit more effective 
management of an illness. Chapters 3 through 5 cover 
a uniform list of topics most relevant to each age 
cluster. Topics include mental health; prevention, 
diagnosis, and treatment of mental illness; service 
delivery; and other services and supports. 

It would be impractical for a report of this type to 
attempt to address every domain of mental health and 
mental illness; therefore, this report casts a spotlight on 
selected topics in each of Chapters 3 through 5. The 
various disorders featured in depth in a given chapter 
were selected on the basis of their prevalence and the 
clinical, societal, and economic burden associated with 
each. To the extent that data permit, the report takes 
note of how gender and culture, in addition to age, 
influence the diagnosis, course, and treatment of mental 
illness. The chapters also note the changing role of 
consumers and families, with attention to informal 
support services (i.e., unpaid services) with which 
patients are so comfortable (Phelan et al., 1997) and 
upon which they depend for information. Patients and 
families welcome a proliferating array of support 
services — such as self-help programs, family self-help, 
crisis services, and advocacy — that help them cope 
with the isolation, family disruption, and possible loss 
of employment and housing that may accompany 
mental disorders. Support services can help dissipate 
stigma and guide patients into formal care as well. 

Although the chapters that address stages of 
development afford a sense of the breadth of issues 
pertinent to mental health and illness, the report is not 
exhaustive. The neglect of any given disorder, 
population, or topic should not be construed as 
signifying a lack of importance. 

Chapter 6 discusses the organization and financing 
of mental health services. The first section provides an 
overview of the current system of mental health 
services, describing where people get care and how 
they use services. The chapter then presents 
information on the costs of care and trends in spending. 
Only within recent decades have the dynamics of 



12 



Introduction and Themes 



insurance financing become a significant issue in the 
mental health field; these are discussed, as is the advent 
of managed care. The chapter addresses both positive 
and adverse effects of managed care on access and 
quality and describes efforts to guard against untoward 
consequences of aggressive cost-containment policies. 
The final section documents some of the inequities 
between general health care and mental health care and 
describes efforts to correct them through legislative 
regulation and financing changes. 

The confidentiality of all health care information 
has emerged as a core issue in recent years, as concerns 
regarding the accessibility of health care information 
and its uses have risen. As Chapter 7 illustrates, privacy 
concerns are particularly keenly felt in the mental 
health field, beginning with the importance of an 
assurance of confidentiality in individual decisions to 
seek mental health treatment. The chapter reviews the 
legal framework governing confidentiality and potential 
problems with that framework, and policy issues that 
must be addressed by those concerned with the 
confidentiality of mental health and substance abuse 
information. 

Chapter 8 concludes, on the basis of the extensive 
literature that the Surgeon General' s report reviews and 
summarizes, that the efficacy of mental health 
treatment is well-documented. Moreover, there exists 
a range of treatments from which people may choose a 
particular approach to suit their needs and preferences. 
Based on this finding, the report's principal 
recommendation to the American people is to seek help 
if you have a mental health problem or think you 
have symptoms of mental illness. The chapter explores 
opportunities to overcome barriers to implementing the 
recommendation and to have seeking help lead to 
effective treatment. 

Chapter Conclusions 

Chapter 2: The Fundamentals of Mental 
Health and Mental Illness 

The past 25 years have been marked by several 
discrete, defining trends in the mental health field. 
These have included: 



1. The extraordinary pace and productivity of 
scientific research on the brain and behavior; 

2. The introduction of a range of effective treatments 
for most mental disorders; 

3. A dramatic transformation of our society's 
approaches to the organization and financing of 
mental health care; and 

4. The emergence of powerful consumer and family 
movements. 

Scientific Research. The brain has emerged as the 
central focus for studies of mental health and mental 
illness. New scientific disciplines, technologies, and 
insights have begun to weave a seamless picture of the 
way in which the brain mediates the influence of 
biological, psychological, and social factors on human 
thought, behavior, and emotion in health and in illness. 
Molecular and cellular biology and molecular genetics, 
which are complemented by sophisticated cognitive and 
behavioral sciences, are preeminent research 
disciplines in the contemporary neuroscience of mental 
health. These disciplines are affording unprecedented 
opportunities for "bottom-up" studies of the brain. This 
term refers to research that is examining the workings 
of the brain at the most fundamental levels. Studies 
focus, for example, on the complex neurochemical 
activity that occurs within individual nerve cells, or 
neurons, to process information; on the properties and 
roles of proteins that are expressed, or produced, by a 
person's genes; and on the interaction of genes with 
diverse environmental influences. All of these activities 
now are understood, with increasing clarity, to underlie 
learning, memory, the experience of emotion, and, 
when these processes go awry, the occurrence of 
mental illness or a mental health problem. 

Equally important to the mental health field is "top- 
down" research; here, as the term suggests, the aim is 
to understand the broader behavioral context of the 
brain' s cellular and molecular activity and to learn how 
individual neurons work together in well-delineated 
neural circuits to perform mental functions. 

Effective Treatments. As information accumulates 
about the basic workings of the brain, it is the task of 
translational research to transfer new knowledge into 
clinically relevant questions and targets of research 



13 



Mental Health: A Report of the Surgeon General 



opportunity — to discover, for example, what specific 
properties of a neural circuit might make it receptive to 
safer, more effective medications. To elaborate on this 
example, theories derived from knowledge about basic 
brain mechanisms are being wedded more closely to 
brain imaging tools such as functional Magnetic 
Resonance Imaging (MRI) that can observe actual brain 
activity. Such a collaboration would permit investi- 
gators to monitor the specific protein molecules 
intended as the "targets" of a new medication to treat a 
mental illness or, indeed, to determine how to optimize 
the effect on the brain of the learning achieved through 
psychotherapy. 

hi its entirety, the new "integrative neuroscience" 
of mental health offers a way to circumvent the 
antiquated split between the mind and the body that 
historically has hampered mental health research. It 
also makes it possible to examine scientifically many of 
the important psychological and behavioral theories 
regarding normal development and mental illness that 
have been developed in years past. The unswerving 
goal of mental health research is to develop and refine 
clinical treatments as well as preventive interventions 
that are based on an understanding of specific 
mechanisms that can contribute to or lead to illness but 
also can protect and enhance mental health. 

Mental health clinical research encompasses 
studies that involve human participants, conducted, for 
example, to test the efficacy of a new treatment. A 
noteworthy feature of contemporary clinical research is 
the new emphasis being placed on studying the 
effectiveness of interventions in actual practice 
settings. Information obtained from such studies 
increasingly provides the foundation for services 
research concerned with the cost, cost-effectiveness, 
and "deliverability" of interventions and the 
design — including economic considerations — of ser- 
vice delivery systems. 

Organization and Financing of Mental Health 
Care. Another of the defining trends has been the 
transformation of the mental illness treatment and 
mental health services landscapes, including increased 
reliance on primary health care and other human 
service providers. Today, the U.S . mental health system 



is multifaceted and complex, comprising the public and 
private sectors, general health and specialty mental 
health providers, and social services, housing, criminal 
justice, and educational agencies. These agencies do 
not always function in a coordinated manner. Its 
configuration reflects necessary responses to a broad 
array of factors including reform movements, financial 
incentives based on who pays for what kind of services, 
and advances in care and treatment technology. 
Although the hybrid system that exists today serves 
diverse functions well for many people, individuals 
with the most complex needs and the fewest financial 
resources often fmd the system fragmented and 
difficult to use. A challenge for the Nation in the near- 
term future is to speed the transfer of new evidence- 
based treatments and prevention interventions into 
diverse service delivery settings and systems, while 
ensuring greater coordination among these settings and 
systems. 

Consumer and Family Movements. The emergence 
of vital consumer and family movements promises to 
shape the direction and complexion of mental health 
programs for many years to come. Although divergent 
in their historical origins and philosophy, organizations 
representing consumers and family members have 
promoted important, often overlapping goals and have 
invigorated the fields of research as well as treatment 
and service delivery design. Among the principal goals 
shared by much of the consumer movement are to 
overcome stigma and prevent discrimination in policies 
affecting persons with mental illness; to encourage self- 
help and a focus on recovery from mental illness; and 
to draw attention to the special needs associated with a 
particular disorder or disability, as well as by age or 
gender or by the racial and cultural identity of those 
who have mental illness. 

Chapter 2 of the report was written to provide 
background information that would help persons from 
outside the mental health field better understand topics 
addressed in subsequent chapters of the report. 
Although the chapter is meant to serve as a mental 
health primer, its depth of discussion supports a range 
of conclusions: 



14 



Introduction and Themes 



1 . The multifaceted complexity of the brain is fully 
consistent with the fact that it supports all behavior 
and mental life. Proceeding from an 
acknowledgment that all psychological experiences 
are recorded ultimately in the brain and that all 
psychological phenomena reflect biological 
processes, the modem neuroscience of mental 
health offers an enriched understanding of the 
inseparability of human experience, brain, and 
mind. 

2. Mental functions, which are disturbed in mental 
disorders, are mediated by the brain. In the process 
of transforming human experience into physical 
events, the brain undergoes changes in its cellular 
structure and function. 

3. Few lesions or physiologic abnormalities define the 
mental disorders, and for the most part their causes 
remain unknown. Mental disorders, instead, are 
defined by signs, symptoms, and functional 
impairments. 

4. Diagnoses of mental disorders made using specific 
criteria are as reliable as those for general medical 
disorders. 

5. About one in five Americans experiences a mental 
disorder in the course of a year. Approximately 15 
percent of all adults who have a mental disorder in 
one year also experience a co-occurring substance 
(alcohol or other drug) use disorder, which 
complicates treatment. 

6. A range of treatments of well-documented efficacy 
exists for most mental disorders. Two broad types 
of intervention include psychosocial treat- 
ments — for example, psychotherapy or 
counseling — and psychopharmacologic treatments; 
these often are most effective when combined. 

7. In the mental health field, progress in developing 
preventive interventions has been slow because, for 
most major mental disorders, there is insufficient 
understanding about etiology (or causes of illness) 
and/or there is an inability to alter the known 
etiology of a particular disorder. Still, some 
successful strategies have emerged in the absence 
of a full understanding of etiology. 



8. About 10 percent of the U.S. adult population use 
mental health services in the health sector in any 
year, with another 5 percent seeking such services 
from social service agencies, schools, or religious 
or self-help groups. Yet critical gaps exist between 
those who need service and those who receive 
service. 

9. Gaps also exist between optimally effective 
treatment and what many individuals receive in 
actual practice settings. 

10. Mental illness and less severe mental health 
problems must be understood in a social and 
cultural context, and mental health services must 
be designed and delivered in a manner that is 
sensitive to the perspectives and needs of racial and 
ethnic minorities. 

11. The consumer movement has increased the 
involvement of individuals with mental disorders 
and their families in mutual support services, 
consumer-run services, and advocacy. They are 
powerful agents for changes in service programs 
and policy. 

12. The notion of recovery reflects renewed optimism 
about the outcomes of mental illness, including that 
achieved through an individual's own self-care 
efforts, and the opportunities open to persons with 
mental illness to participate to the full extent of 
their interests in the community of their choice. 

Mental Health and Mental Illness Across the 
Lifespan 

The Surgeon General's report takes a lifespan ap- 
proach to its consideration of mental health and mental 
illness. Three chapters that address, respectively, the 
periods of childhood and adolescence, adulthood, and 
later adult life beginning somewhere between ages 55 
and 65, capture the contributions of research to the 
breadth, depth, and vibrancy that characterize all facets 
of the contemporary mental health field. 

The disorders featured in depth in Chapters 3, 4, 
and 5 were selected on the basis of the frequency with 
which they occur in our society, and the clinical, 
societal, and economic burden associated with each. To 
the extent that data permit, the report takes note of how 



15 



Mental Health: A Report of the Surgeon General 



gender and culture, in addition to age, influence the 
diagnosis, course, and treatment of mental illness. The 
chapters also note the changing role of consumers and 
families, with attention to informal support services 
(i.e., unpaid services), with which many consumers are 
comfortable and upon which they depend for 
information. Persons with mental illness and, often, 
their families welcome a proliferating array of support 
services — such as self-help programs, family self-help, 
crisis services, and advocacy — that help them cope 
with the isolation, family disruption, and possible loss 
of employment and housing that may accompany 
mental disorders. Support services can help to dissipate 
stigma and to guide patients into formal care as well. 

Mental health and mental illness are dynamic, ever- 
changing phenomena. At any given moment, a person' s 
mental status reflects the sum total of that individual's 
genetic inheritance and life experiences. The brain 
interacts with and responds — both in its function and in 
its very structure — to multiple influences continuously, 
across every stage of life. At different stages, 
variability in expression of mental health and mental 
illness can be very subtle or very pronounced. As an 
example, the symptoms of separation anxiety are 
normal in early childhood but are signs of distress in 
later childhood and beyond. It is all too common for 
people to appreciate the impact of developmental 
processes in children, yet not to extend that conceptual 
understanding to older people. In fact, people continue 
to develop and change throughout life. Different stages 
of life are associated with vulnerability to distinct 
forms of mental and behavioral disorders but also with 
distinctive capacities for mental health. 

Even more than is true for adults, children must be 
seen in the context of their social environments — that 
is, family and peer group, as well as that of their larger 
physical and cultural surroundings. Childhood mental 
health is expressed in this context, as children proceed 
along the arc of development. A great deal of 
contemporary research focuses on developmental 
processes, with the aim of understanding and predicting 
the forces that will keep children and adolescents 
mentally healthy and maintain them on course to 
become mentally healthy adults. Research also focuses 



on identifying what factors place some at risk for 
mental illness and, yet again, what protects some 
children but not others despite exposure to the same 
risk factors. In addition to studies of normal 
development and of risk factors, much research focuses 
on mental disorders in childhood and adolescence and 
what can be done to prevent or treat these conditions 
and on the design and operation of service settings best 
suited to the needs experienced by children. 

For about one in five Americans, adulthood — a 
time for achieving productive vocations and for 
sustaining close relationships at home and in the 
community — is interrupted by mental illness. 
Understanding why and how mental disorders occur in 
adulthood, often with no apparent portents of illness in 
earlier years, draws heavily on the full panoply of 
research conducted under the aegis of the mental health 
field. In years past, the onset, or occurrence, of mental 
illness in the adult years, was attributed principally to 
observable phenomena — for example, the burden of 
stresses associated with career or family, or the 
inheritance of a disease viewed to run in a particular 
family. Such explanations now may appear naive at 
best. Contemporary studies of the brain and behavior 
are racing to fill in the picture by elucidating specific 
neurobiological and genetic mechanisms that are the 
platform upon which a person's life experiences can 
either strengthen mental health or lead to mental 
illness. It now is recognized that factors that influence 
brain development prenatally may set the stage for a 
vulnerability to illness that may lie dormant throughout 
childhood and adolescence. Similarly, no single gene 
has been found to be responsible for any specific 
mental disorder; rather, variations in multiple genes 
contribute to a disruption in healthy brain function that, 
under certain environmental conditions, results in a 
mental illness. Moreover, it is now recognized that 
socioeconomic factors affect individuals' vulnerability 
to mental illness and mental health problems. Certain 
demographic and economic groups are more likely than 
others to experience mental health problems and some 
mental disorders. Vulnerability alone may not be 
sufficient to cause a mental disorder; rather, the causes 
of most mental disorders lie in some combination of 



16 



Introduction and Themes 



genetic and environmental factors, which may be 
biological or psychosocial. 

The fact that many, if not most, people have 
experienced mental health problems that mimic or even 
match some of the symptoms of a diagnosable mental 
disorder tends, ironically, to prompt many people to 
underestimate the painful, disabling nature of severe 
mental illness. In fact, schizophrenia, mood disorders 
such as major depression and bipolar illness, and 
anxiety often are devastating conditions. Yet relatively 
few mental illnesses have an unremitting course mark- 
ed by the most acute manifestations of illness; rather, 
for reasons that are not yet understood, the symptoms 
associated with mental illness tend to wax and wane. 
These patterns pose special challenges to the 
implementation of treatment plans and the design of 
service systems that are optimally responsive to an 
individual's needs during every phase of illness. As this 
report concludes, enormous strides are being made in 
diagnosis, treatment, and service delivery, placing the 
productive and creative possibilities of adulthood 
within the reach of persons who are encumbered by 
mental disorders. 

Late adulthood is when changes in health status 
may become more noticeable and the ability to 
compensate for decrements may become limited. As the 
brain ages, a person's capacity for certain mental tasks 
tends to diminish, even as changes in other mental 
activities prove to be positive and rewarding. Well into 
late life, the ability to solve novel problems can be 
enhanced through training in cognitive skills and 
problem-solving strategies. 

The promise of research on mental health 
promotion notwithstanding, a substantial minority of 
older people are disabled, often severely, by mental 
disorders including Alzheimer's disease, major 
depression, substance abuse, anxiety, and other 
conditions. In the United States today, the highest rate 
of suicide — an all-too-common consequence of 
unrecognized or inappropriately treated depression — is 
found in older males. This fact underscores the urgency 
of ensuring that health care provider training properly 
emphasizes skills required to differentiate accurately 
the causes of cognitive, emotional, and behavioral 



symptoms that may, in some instances, rise to the level 
of mental disorders, and in other instances be 
expressions of unmet general medical needs. 

As the life expectancy of Americans continues to 
extend, the sheer number — although not necessarily the 
proportion — of persons experiencing mental disorders 
of late life will expand, confronting our society with 
unprecedented challenges in organizing, financing, and 
delivering effective mental health services for this 
population. An essential part of the needed societal 
response will include recognizing and devising 
innovative ways of supporting the increasingly more 
prominent role that families are assuming in caring for 
older, mentally impaired and mentally ill family 
members. 

Chapter 3: Children and Mental Health 

1 . Childhood is characterized by periods of transition 
and reorganization, making it critical to assess the 
mental health of children and adolescents in the 
context of familial, social, and cultural 
expectations about age-appropriate thoughts, 
emotions, and behavior. 

2. The range of what is considered "normal" is wide; 
still, children and adolescents can and do develop 
mental disorders that are more severe than the "ups 
and downs" in the usual course of development. 

3 . Approximately one in five children and adolescents 
experiences the signs and symptoms of a DSM-IV 
disorder during the course of a year, but only about 
5 percent of all children experience what 
professionals term "extreme functional impair- 
ment." 

4. Mental disorders and mental health problems 
appear in families of all social classes and of all 
backgrounds. No one is immune. Yet there are 
children who are at greatest risk by virtue of a 
broad array of factors. These include physical 
problems; intellectual disabilities (retardation); low 
birth weight; family history of mental and addictive 
disorders; multigenerational poverty; and caregiver 
separation or abuse and neglect. 

5. Preventive interventions have been shown to be 
effective in reducing the impact of risk factors for 



17 



Mental Health: A Report of the Surgeon General 



mental disorders and improving social and 
emotional development by providing, for example, 
educational programs for young children, parent- 
education programs, and nurse home visits. 

6. A range of efficacious psychosocial and 
pharmacologic treatments exists for many mental 
disorders in children, including attention- 
deficit/hyperactive disorder, depression, and the 
disruptive disorders. 

7. Research is under way to demonstrate the 
effectiveness of most treatments for children in 
actual practice settings (as opposed to evidence of 
"efficacy" in controlled research settings), and 
significant barriers exist to receipt of treatment. 

8. Primary care and the schools are major settings for 
the potential recognition of mental disorders in 
children and adolescents, yet trained staff are 
limited, as are options for referral to specialty care. 

9. The multiple problems associated with "serious 
emotional disturbance" in children and adolescents 
are best addressed with a "systems" approach in 
which multiple service sectors work in an 
organized, collaborative way. Research on the 
effectiveness of systems of care shows positive 
results for system outcomes and functional 
outcomes for children; however, the relationship 
between changes at the system level and clinical 
outcomes is still unclear. 

10. Families have become essential partners in the 
delivery of mental health services for children and 
adolescents. 

11. Cultural differences exacerbate the general 
problems of access to appropriate mental health 
services. Culturally appropriate services have been 
designed but are not widely available. 

Chapter 4: Adults and Mental Health 

1. As individuals move into adulthood, develop- 
mental goals focus on productivity and intimacy 
including pursuit of education, work, leisure, 
creativity, and personal relationships. Good mental 
health enables individuals to cope with adversity 
while pursuing these goals. 



2. Untreated, mental disorders can lead to lost 
productivity, unsuccessful relationships, and 
significant distress and dysfunction. Mental illness 
in adults can have a significant and continuing 
effect on children in their care. 

3. Stressful life events or the manifestation of mental 
illness can disrupt the balance adults seek in life 
and result in distress and dysfunction. Severe or 
life-threatening trauma experienced either in 
childhood or adulthood can further provoke 
emotional and behavioral reactions that jeopardize 
mental health. 

4. Research has improved our understanding of 
mental disorders in the adult stage of the life cycle. 
Anxiety, depression, and schizophrenia, 
particularly, present special problems in this age 
group. Anxiety and depression contribute to the 
high rates of suicide in this population. 
Schizophrenia is the most persistently disabling 
condition, especially for young adults, in spite of 
recovery of function by some individuals in mid to 
late life. 

5. Research has contributed to our ability to 
recognize, diagnose, and treat each of these 
conditions effectively in terms of symptom control 
and behavior management. Medication and other 
therapies can be independent, combined, or 
sequenced depending on the individual' s diagnosis 
and personal preference. 

6. A new recovery perspective is supported by 
evidence on rehabilitation and treatment as well as 
by the personal experiences of consumers. 

7. Certain common events of midlife (e.g., divorce or 
other stressful life events) create mental health 
problems (not necessarily disorders) that may be 
addressed through a range of interventions. 

8. Care and treatment in the real world of practice do 
not conform to what research determines is best. 
For many reasons, at times care is inadequate, but 
there are models for improving treatment. 

9. Substance abuse is a major co-occurring problem 
for adults with mental disorders. Evidence supports 
combined treatment, although there are substantial 



18 



Introduction and Themes 



gaps between what research recommends and what 
typically is available in communities. 

10. Sensitivity to culture, race, gender, disability, 
poverty, and the need for consumer involvement 
are important considerations for care and treatment. 

11. Barriers of access exist in the organization and 
financing of services for adults. There are specific 
problems with Medicare, Medicaid, income 
supports, housing, and managed care. 

Chapter 5: Older Adults and Mental Health 

1 . Lnportant life tasks remain for individuals as they 
age. Older individuals continue to learn and 
contribute to the society, in spite of physiologic 
changes due to aging and increasing health 
problems. 

2. Continued intellectual, social, and physical activity 
throughout the life cycle are important for the 
maintenance of mental health in late life. 

3. Stressful life events, such as declining health 
and/or the loss of mates, family members, or 
friends often increase with age. However, 
persistent bereavement or serious depression is not 
"normal" and should be treated. 

4. Normal aging is not characterized by mental or 
cognitive disorders. Mental or substance use 
disorders that present alone or co-occur should be 
recognized and treated as illnesses. 

5. Disability due to mental illness in individuals over 
65 years old will become a major public health 
problem in the near future because of demographic 
changes, hi particular, dementia, depression, and 
schizophrenia, among other conditions, will all 
present special problems in this age group: 

a. Dementia produces significant dependency and 
is a leading contributor to the need for costly 
long-term care in the last years of life; 

b. Depression contributes to the high rates of 
suicide among males in this population; and 

c. Schizophrenia continues to be disabling in 
spite of recovery of function by some 
individuals in mid to late life. 

6. There are effective interventions for most mental 
disorders experienced by older persons (for 



example, depression and anxiety), and many 
mental health problems, such as bereavement. 

7. Older individuals can benefit from the advances in 
psychotherapy, medication, and other treatment 
interventions for mental disorders enjoyed by 
younger adults, when these interventions are 
modified for age and health status. 

8 . Treating older adults with mental disorders accrues 
other benefits to overall health by improving the 
interest and ability of individuals to care for 
themselves and follow their primary care 
provider' s directions and advice, particularly about 
taking medications. 

9. Primary care practitioners are a critical link in 
identifying and addressing mental disorders in 
older adults. Opportunities are missed to improve 
mental health and general medical outcomes when 
mental illness is underrecognized and undertreated 
in primary care settings. 

10. Barriers to access exist in the organization and 
financing of services for aging citizens. There are 
specific problems with Medicare, Medicaid, 
nursing homes, and managed care. 

Chapter 6: Organization and Financing of 
Mental Health Services 

hi the United States in the late 20th century, research- 
based capabilities to identify, treat, and, in some 
instances, prevent mental disorders is outpacing the 
capacities of the service system the Nation has in place 
to deliver mental health care to all who would benefit 
from it. Approximately 10 percent of children and 
adults receive mental health services from mental 
health specialists or general medical providers in a 
given year. Approximately one in six adults, and one in 
five children, obtain mental health services either from 
health care providers, the clergy, social service 
agencies, or schools in a given year. 

Chapter 6 discusses the organization and financing 
of mental health services. The chapter provides an 
overview of the current system of mental health 
services, describing where people get care and how 
they use services. The chapter then presents 
information on the costs of care and trends in spending. 



19 



Mental Health: A Report of the Surgeon General 



Only within recent decades, in the face of concerns 
about discriminatory policies in mental health 
financing, have the dynamics of insurance financing 
become a significant issue in the mental health field. In 
particular, policies that have emphasized cost 
containment have ushered in managed care, hitensive 
research currently is addressing both positive and 
adverse effects of managed care on access and quality, 
generating information that will guard against untoward 
consequences of aggressive cost-containment policies. 
Inequities in insurance coverage for mental health and 
general medical care — the product of decades of stigma 
and discrimination — have prompted efforts to correct 
them through legislation designed to produce financing 
changes and create parity. Parity calls for equality 
between mental health and other health coverage. 

1 . Epidemiologic surveys indicate that one in five 
Americans has a mental disorder in any one year. 

2. Fifteen percent of the adult population use some 
form of mental health service during the year. Eight 
percent have a mental disorder; 7 percent have a 
mental health problem. 

3. Twenty-one percent of children ages 9 to 17 
receive mental health services in a year. 

4. The U.S. mental health service system is complex 
and connects many sectors (public-private, 
specialty-general health, health-social welfare, 
housing, criminal justice, and education). As a 
result, care may become organizationally 
fragmented, creating barriers to access. The system 
is also financed from many funding streams, 
adding to the complexity, given sometimes 
competing incentives between funding sources. 

5. In 1996, the direct treatment of mental disorders, 
substance abuse, and Alzheimer's disease cost the 
Nation $99 billion; direct costs for mental 
disorders alone totaled $69 billion. In 1990, 
indirect costs for mental disorders alone totaled 
$79 bilhon. 

6. Historically, financial barriers to mental health 
services have been attributable to a variety of 
economic forces and concerns (e.g., market failure, 
adverse selection, moral hazard, and public 
provision). This has accounted for differential 



resource allocation rules for financing mental 
health services. 

a. "Parity" legislation has been a partial solution 
to this set of problems. 

b. Implementing parity has resulted in negligible 
cost increases where the care has been 
managed. 

7. In recent years, managed care has begun to 
introduce dramatic changes into the organization 
and financing of health and mental health services. 

8. Trends indicate that in some segments of the 
private sector per capita mental health expenditures 
have declined much faster than they have for other 
conditions. 

9. There is little direct evidence of problems with 
quality in well-implemented managed care 
programs. The risk for more impaired populations 
and children remains a serious concern. 

10. An array of quality monitoring and quality 
improvement mechanisms has been developed, 
although incentives for their full implementation 
has yet to emerge. In addition, competition on the 
basis of quality is only beginning in the managed 
care industry. 

11. There is increasing concern about consumer 
satisfaction and consumers' rights. A Consumers 
Bill of Rights has been developed and implemented 
in Federal Employee Health Benefit Plans, with 
broader legislation currently pending in the 
Congress. 

Chapter 7: Confidentiality of Mental Health 
Information: Ethical, Legal, and Policy Issues 

In an era in which the confidentiality of all health care 
information, its accessibility, and its uses are of 
concern to all Americans, privacy issues are 
particularly keenly felt in the mental health field. An 
assurance of confidentiality is understandably critical 
in individual decisions to seek mental health treatment. 
Although an extensive legal framework governs 
confidentiality of consumer-provider interactions, 
potential problems exist and loom ever larger. 



20 



Introduction and Themes 



1. People's willingness to seek help is contingent on 
their confidence that personal revelations of mental 
distress will not be disclosed without their consent. 

2. The U.S. Supreme Court recently has upheld the 
right to the privacy of these records and the 
therapist-client relationship. 

3. Although confidentiality issues are common to 
health care in general, there are special concerns 
for mental health care and mental health care 
records because of the extremely personal nature of 
the material shared in treatment. 

4. State and Federal laws protect the confidentiality 
of health care information but are often incomplete 
because of numerous exceptions which often vary 
from state to state. Several states have imple- 
mented or proposed models for protecting privacy 
that may serve as a guide to others. 

5. States, consumers, and family advocates take 
differing positions on disclosure of mental health 
information without consent to family caregivers. 
In states that allow such disclosure, information 
provided is usually limited to diagnosis, prognosis, 
and information regarding treatment, specifically 
medication. 

6. When conducting mental health research, it is in 
the interest of both the researcher and the 
individual participant to address informed consent 
and to obtain certificates of confidentiality before 
proceeding. Federal regulations require informed 
consent for research being conducted with Federal 
funds. 

7 . New approaches to managing care and information 
technology threaten to further erode the 
confidentiality and trust deemed so essential 
between the direct provider of mental health 
services and the individual receiving those 
services. It is important to monitor advances so that 
confidentiality of records is enhanced, instead of 
impinged upon, by technology. 

8. Until the stigma associated with mental illnesses is 
addressed, confidentiality of mental health 
information will continue to be a critical point of 
concern for payers, providers, and consumers. 



Chapter 8: A Vision for the Future — 
Actions for Mental Health in the New 
Millennium 

The extensive literature that the Surgeon General's 
report reviews and summarizes leads to the conclusion 
that a range of treatments of documented efficacy 
exists for most mental disorders. Moreover, a person 
may choose a particular approach to suit his or her 
needs and preferences. Based on this finding, the 
report's principal recommendation to the American 
people is to seek help if you have a mental health 
problem or think you have symptoms of a mental 
disorder. As noted earlier, stigma interferes with the 
willingness of many people — even those who have a 
serious mental illness — to seek help. And, as 
documented in this report, those who do seek help will 
all too frequently learn that there are substantial gaps in 
the availability of state-of-the-art mental health services 
and barriers to their accessibility. Accordingly, the final 
chapter of the report goes on to explore opportunities to 
overcome barriers to implementing the 
recommendation and to have seeking help lead to 
effective treatment. 

The final chapter identifies the following courses 
of action. 

1. Continue to Build the Science Base: Today, 
integrative neuroscience and molecular genetics 
present some of the most exciting basic research 
opportunities in medical science. A plethora of new 
pharmacologic agents and psychotherapies for 
mental disorders afford new treatment 
opportunities but also challenge the scientific 
community to develop new approaches to clinical 
and health services interventions research. Because 
the vitality and feasibility of clinical research 
hinges on the willing participation of clinical 
research volunteers, it is important for society to 
ensure that concerns about protections for 
vulnerable research subjects are addressed. 
Responding to the calls of managed mental and 
behavioral health care systems for evidence-based 
interventions will have a much needed and 
discernible impact on practice. Special effort is 
required to address pronounced gaps in the mental 



21 



Mental Health: A Report of the Surgeon General 



health knowledge base. Key among these are the 
urgent need for evidence which supports strategies 
for mental health promotion and illness prevention. 
Additionally, research that explores approaches for 
reducing risk factors and strengthening protective 
factors for the prevention of mental illness should 
be encouraged. As noted throughout the report, 
high-quality research and the effective services it 
promotes are a potent weapon against stigma. 

2. Overcome Stigma: Powerful and pervasive, stigma 
prevents people from acknowledging their own 
mental health problems, much less disclosing them 
to others. For our Nation to reduce the burden of 
mental illness, to improve access to care, and to 
achieve urgently needed knowledge about the 
brain, mind, and behavior, stigma must no longer 
be tolerated. Research on brain and behavior that 
continues to generate ever more effective 
treatments for mental illnesses is a potent antidote 
to stigma. The issuance of this Surgeon General's 
Report on Mental Health seeks to help reduce 
stigma by dispelling myths about mental illness, by 
providing accurate knowledge to ensure more 
informed consumers, and by encouraging help 
seeking by individuals experiencing mental health 
problems. 

3 . Improve Public Awareness of Effective Treatment: 
Americans are often unaware of the choices they 
have for effective mental health treatments, hi fact, 
there exists a constellation of several treatments of 
documented efficacy for most mental disorders. 
Treatments fall mainly under several broad catego- 
ries — counseling, psychotherapy, medication ther- 
apy, rehabilitation — yet within each category are 
many more choices. All human services 
professionals, not just health professionals, have an 
obligation to be better informed about mental health 
treatment resources in their communities and should 
encourage individuals to seek help from any source 
in which they have confidence. 

4. Ensure the Supply of Mental Health Services and 
Providers : The fundamental components of effect! ve 
service delivery, which include integrated 
community-based services, continuity of providers 



and treatments, family support services (including 
psychoeducation), and culturally sensitive services, 
are broadly agreed upon, yet certain of these and 
other mental health services are in consistently short 
supply, both regionally and, in some instances, 
nationally. Because the service system as a whole, as 
opposed to treatment services considered in 
isolation, dictates the outcome of recovery-oriented 
mental health care, it is imperative to expand the 
supply of effective, evidence-based services 
throughout the Nation. Key personnel shortages 
include mental health professionals serving 
children/adolescents and older people with serious 
mental disorders and specialists with expertise in 
cognitive-behavioral therapy and interpersonal 
therapy, two forms of psychotherapy that research 
has shown to be effective for several severe mental 
disorders. For adults and children with less severe 
conditions, primary health care, the schools, and 
otherhuman services mustbepreparedto assess and, 
at times, to treat individuals who come seeking help. 

5. Ensure Delivery of State-of-the-ArtTreatments: A 
wide variety of effective, community-based services, 
carefully refined through years of research, exist for 
even the most severe mental illnesses yet are not 
being translated into community settings . Numerous 
explanations for the gap between what is known from 
research and what is practiced beg for innovative 
strategies to bridge it. 

6. Tailor Treatment to Age, Gender, Race, and 
Culture: Mental illness, no less than mental health, 
is influenced by age, gender, race, and culture as well 
as additional facets of diversity that can be found 
within all of these population groups — for example, 
physical disability or a person's sexual orientation 
choices. To beeffective,thediagnosis and treatment 
of mental illness must be tailored to all 
characteristics that shape a person's image and 
identity. The consequences of not understanding 
these influences can be profoundly deleterious. 
"Culturally competent" services incorporate 
understanding of racial and ethnic groups, their 
histories, traditions, beliefs, and value systems. With 
appropriate training and a fundamental respect for 



22 



Introduction and Themes 



clients, any mental health professional can provide 
culturally competent services that reflect sensitivity 
to individual differences and, at the same time, assign 
validity to an individual's group identity. 
Nonetheless, the preference of many members of 
ethnic and racial minority groups to be treated by 
mental health professionals of similar background 
underscores the need to redress the current 
insufficient supply of mental health professionals 
who are members of racial and ethnic minority 
groups. 

7. Facilitate Entry Into Treatment: Public and private 
agencies have an obligation to facilitate entry into 
mental health care and treatment through the 
multiple "portals of entry" that exist: primary health 
care, schools, and the child welfare system. To 
enhance adherence to treatment, agencies should 
offer services that are responsive to the needs and 
preferences of service users and their families. At the 
same time, some agencies receive inappropriate 
referrals. For example, an alarming number of 
children and adults with mental illness are in the 
criminal justice system inappropriately, hnportantly, 
assuring the small number of individuals with severe 
mental disorders who pose a threat of danger to 
themselves or others ready access to adequate and 
appropriate services promises to reduce significantly 
the need for coercion in the form of involuntary 
commitment to a hospital and/or certain outpatient 
treatment requirements that have been legislated in 
most states and territories. Coercion should not be a 
substitute for effective care that is sought 
voluntarily; consensus on this point testifies to the 
need for research designed to enhance adherence to 
treatment. 

8 . Reduce Financial Barriers to Treatment: Concerns 
about the cost of care — concerns made worse by the 
disparity in insurance coverage for mental disorders 
in contrast to other illnesses — are among the 
foremost reasons why people do not seek needed 
mental health care. While both access to and use of 
mental health services increase when benefits for 
those services are enhanced, preliminary data show 
that the effectiveness — and, thus, the value — of 



mental health care also has increased in recent years, 
while expenditures for services, under managed care, 
have fallen. Equality between mental health 
coverage and other health coverage — a concept 
known as parity — is an affordable and effective 
objective. 

Scope of Coverage of the Report 

This report is comprehensive but not exhaustive in its 
coverage of mental health and mental illness. It considers 
mental health facets of some conditions which are not 
always associated with the mental disorders and does not 
consider all conditions which can be found in 
classifications of mental disorders such as DSM-IV. The 
report includes, for example, a discussion of autism in 
Chapter 3 and provides an extensive section on 
Alzheimer's disease in Chapter 5. Although DSM-IV 
lists specific mental disorder criteria for both of these 
conditions, they often are viewed as being outside the 
scope of the mental health field. In both cases, mental 
health professionals are involved in the diagnosis and 
treatment of these conditions, often characterized by 
cognitive and behavioral impairments. The 
developmental disabilities and mental retardation are not 
discussed except in passing in this report. These 
conditions were considered to be beyond its scope with a 
care system all their own and very special needs. The 
same is generally true for the addictive disorders, such as 
alcohol and other drug use disorders . The latter, however, 
co-occur with such frequency with the other mental 
disorders, which are the focus of this report, that the co- 
occurrenceisdiscussed throughout. The report covers the 
epidemiology of addictive disorders and their co- 
occurrence with other mental disorders as well as the 
treatment of co-occurring conditions. Brief sections on 
substance abuse in adolescence and late life also are 
included in the report. 

Preparation of the Report 

In September 1997, the Office of the Surgeon General, 
with the approval of the Secretary of the Department of 
Health and Human Services, authorized the Substance 
Abuse and Mental Health Services Administration 
(SAMHSA) to serve as lead operating division for 



23 



Mental Health: A Report of the Surgeon General 



preparing the first Surgeon General' s Report on Mental 
Health. SAMHSA's Center for Mental Health Services 
worked in partnership with the National Institute of 
Mental Health of the National Institutes of Health to 
develop this report under the guidance of Surgeon 
General David Satcher. These Federal partners 
established a Planning Board comprising individuals 
representing a broad range of expertise in mental 
health, including academicians, mental health 
professionals, researchers in neuroscience and service 
delivery, and self-identified consumers of mental health 
services and family members of consumers of mental 
health services. Also included on the Planning Board 
were individuals representing Federal operating 
divisions, offices, centers, and institutes and private 
nonprofit foundations with interests in mental health. 

References 

American Psychiatric Association. (1994). Diagnostic and 
statistical manual of mental disorders (4th ed.). 
Washington, DC: Author. 

Angermeyer, M. C, & Matschinger, H. (1996). The effect of 
violent attacks by schizophrenic persons on the attitude 
of the public towards the mentally ill. Social Science 
Medicine, 43, 1721-1728. 

Bachrach, L. L. (1996). The state of the state mental hospital 
1996. Psychiatric Services, 47, 1071-1078. 

Baum, A., & Posluszny, D. M. (1999). Health psychology: 
Mapping biobehavioral contributions to health and 
iWne&s. Annual Review of Psychology, 50, 137-163. 

Chambless, D. L., Sanderson, W. C, Shohman, V., Bennett, 
J. S., Pope, K. S., Crits-Cristoph, P., Baker, M., 
Johnson, B., Woody, S. R., Sue, S., Beutler, L., 
Williams, D. A., & McMurry, S. (1996). An update on 
empirically validated therapies. Clinical Psychologist, 
49,5-18. 

Cohen, S., & Herbert. T. B. (1996). Health psychology: 
Psychological factors and physical disease from the 
perspective of human psychoneuroimmunology. Annual 
Review of Psychology, 47, 113-142. 

Conwell, Y. (1996). Diagnosis and treatment of depression 
in late life. Washington, DC: American Psychiatric 
Press. 



Cooper-Patrick, L., Powe, N. R., Jenckes, M. W., Gonzales, 

J. J., Levine, D. M., & Ford, D. E. (1997). Identification 

of patient attitudes and preferences regarding treatment 

of depression. Journal of General Internal Medicine, 12, 

431-^38. 
Corrigan, P. W. & Penn, D. L. (1999). Lessons from social 

psychology on discrediting psychiatric stigma. American 

Psychologist, 54, 765-776. 
Cowen, E. L. (1994). The enhancement of psychological 

wellness: Challenges and opportunities. American 

Journal of Community Psychology, 22, 149-179. 
DiMasi, J. A., & Lasagna, L. (1995). The economics of 

psychotropic drug development. In F. E. Bloom & D. J. 

Kupfer (Eds.), Psychopharmacology: The fourth 

generation of progress, (pp. 1883-1895). New York: 

Raven Press. 
DSM-IV. See American Psychiatric Association (1994). 
Eisendrath, S. J., & Feder, A. (in press). The mind and 

somatic illness: Psychological factors affecting physical 

illness. In H. H. Goldman (Ed.), Review of general 

psychiatry (5th ed.). Norwalk, CT: Appleton & Lange. 
Eronen, M., Angermeyer, M. C, & Schulze, B. (1998). The 

psychiatric epidemiology of violent behaviour. Social 

Psychiatry and Psychiatric Epidemiology, ii(Suppl. 1), 

S13-S23. 
Fischbach, G. D. (1992). Mind and brain. Scientific 

American, 267, 48-57. 
Food and Drug Administration. (1998). Center for Drug 

Evaluation and Research handbook [On-line]. 

Available: http://www.fda.gov/cder/ handbook- 

/index.htm 
Erasure-Smith, N., Lesperance, F., & Talajic, M. (1993). 

Depression following myocardial infarction. Impact on 

6-month survival. Journal of the American Medical 

Association, 270, 1819-1825. 
Frasure-Smith, N., Lesperance, F., & Talajic, M. (1995). 

Depression and 18-month prognosis after myocardial 

infarction. Circulation, 91, 999-1005. 
Gazzaniga, M. S., Ivry, R. B., & Mangun, G. R. (1998). 

Cognitive neuroscience: The biology of the mind. New 

York: W. W. Norton. 
Grob, G. N. (1983). Mental illness and American society, 

1875-1940. Princeton, NJ: Princeton University Press. 
Grob, G. N. (1991). From asylum to community. Mental 

health policy in modern America. Princeton, NJ: 

Princeton University Press. 



24 



Introduction and Themes 



Grob, G.N .(1994). The madamong us: Ahistory of the care of 
America's mentally ill. New York: Free Press. 

Gurin, J., Veroff, J., & Feld, S. (1960). Americans view their 
mental health: Anationwide interview survey (Areportto 
the staff director, JackR. Ewalt). New York: Basic Books. 

Hanson, K. W. (1998). Public opinion and the mental health 
parity debate: Lessons from the survey literature. 
Psychiatric Services, 49, 1059-1066. 

Heginbotham,C.( 1998). UKmentalhealth policy can alterthe 
stigmaof mental illness. L<3«ce/, 352, 1052-1053. 

Hoyt, D. R., Conger, R. D., Valde, J. G., & Weihs, K. (1997). 
Psychological distress and help seeking in rural America. 
American Journal of Community Psychology, 25, 
449^70. 

Jones, A. H. (1998). Mental illness made pubhc: Ending the 
stigma! Lancet, 352, 1060. 

Kandel, E. R. (1998). A new intellectual framework for 
psychiatry. American Journal of Psychiatry, 155, 
457-469. 

Kessler, R. C, Nelson, C. B ., McKinagle, K. A., Edlund, M. J., 
Frank, R.G.,&Leaf,P. J. (1996). Theepidemiology of co- 
occurring addictive and mental disorders : Implications for 
prevention and service utilization. American Journal of 
Orthopsychiatry, 66, 17-31. 

Last, J.M.,& Wallace, R.B. (Eds.). (1992).Ma;cc3'-/?05enaM- 
Last public health and preventive medicine (13th ed.). 
Norwalk, CT: Appleton andLange. 

Link,B.,Phelan,J.,Bresnahan,M.,Stueve,A.,&Pescosolido, 
B. (in press). Public conceptions of mental illness: The 
labels, causes, dangerousness and social distance. 
American Journal of Public Health. 

Murray, C. J. L., & Lopez, A. D. (Eds.). (1996). The global 
burden of disease. A comprehensive assessment of 
mortality and disability from diseases, injuries, and risk 
factors in 1990 and projected to 2020. Cambridge, MA: 
Harvard School of Public Health. 

Penn, D. L., & Martin, J. ( 1 998). The stigma of severe mental 
illness: Some potential solutions for a recalcitrant 
problem. Psychiatric Quarterly, 69, 235-241 . 

Phelan, J., Link, B., Stueve, A., & Pescosolido, B. (1997, 
August). Public conceptions of mental illness in 1950 in 
1996: Has sophistication increased? Has stigma 
declined? Paperpresented at the meeting of the American 
Sociological Association, Toronto, Ontario. 



Regier,D. A., Narrow, W.E.,Rae,D.S.,Manderscheid,R.W., 
Locke, B. Z., & Goodwin, F. K. (1993). The de facto US 
mental and addictive disorders service system. 
Epidemiologic Catchment Area prospective 1-year 
prevalence rates of disorders and services. Archives of 
General Psychiatry, 50, 85-94. 

Seeker, J. ( 1 998). Current conceptualizations of mental health 
and mental health promotion . Health Education Re sea rch, 
13, 57-66. 

Star, S. A. (1952). What the public thinks about mental health 
and mental illness. Paper presented at the annual meeting 
of the National Association for Mental Health. 

Star, S. A. (1955). The public's ideas about mental illness. 
Paper presented at the annual meeting of the National 
Association for Mental Health. 

Steadman, H. J., Mulvey, E. P., Monahan, J., Robbins, P. C, 
Appelbaum, P. S., Grisso, T., Roth, L. H., & Silver, E. 
(1998). Violence by people discharged from acute 
psychiatric inpatient facilities and by others in the same 
neighborhoods. Archives of General Psychiatry, 55, 
393-401. 

Sussman, L. K., Robins, L. N., & Earls, F. (1987). Treatment- 
seeking for depression by black and white Americans. 
Social Science and Medicine, 24, 187-196. 

Swanson, J. W. ( 1 994). Mental disorder, substance abuse, and 
community violence: An epidemiological approach. In J. 
Monahan & H. J. Steadman (Eds.), Violence and mental 
disorder: Developments inriskassessmentipp. 101-136). 
Chicago: University of Chicago Press. 

Swartz, M. S., Swanson, J. W., &Bums, B. J. (1998). Taking 
the wrong drugs: The role of substance abuse and 
medication noncompliance in violence among severely 
mentaWyiU'mdividuah. Social Psychiatry andPsychiatric 
Epidemiology, Ji(Suppl. 1), S75-S80. 

Swindle, R., Heller, K., & Pescosolido, B. (1997, August). 
Responses to "nervous breakdowns " in America over a 
40-year period: Mental healthpolicy implications. Paper 
presented at the meeting of American Sociological 
Association, Toronto, Ontario. 

Veroff,J.,Douvan,E.,&Kulka,R.A.(1981).Menra/;iea/r/zm 
America: Patterns of help-seeking from 1957 to 1976. 
New York: Basic Books. 

Zisook, S., & Shuchter, S. R. ( 1991). Depression through the 
first year after the death of a spouse . American Journal of 
Psychiatry, 148, 1346-1352. 

Zisook, S., & Shuchter, S. R. (1993). Major depression 
associated with widowhood. American Journal of 
Geriatric Psychiatry, 7,31 6-326. 



25 



Chapter 2 

The Fundamentals of Mental Health 

AND Mental Illness 



Contents 

The Neuroscience of Mental Health 32 

Complexity of the Brain I: Structural 32 

Complexity of the Brain H: Neurochemical 36 

Complexity of the Brain HI: Plasticity 38 

Lnaging the Brain 38 

Overview of Mental Illness 39 

Manifestations of Mental Illness 40 

Anxiety 40 

Psychosis 41 

Disturbances of Mood 42 

Disturbances of Cognition 43 

Other Symptoms 43 

Diagnosis of Mental Illness 43 

Epidemiology of Mental Illness 45 

Adults 46 

Children and Adolescents 46 

Older Adults 48 

Future Directions for Epidemiology 48 

Costs of Mental Illness 49 

Overview of Etiology 49 

Biopsychosocial Model of Disease 50 

Understanding Correlation, Causation, and Consequences 51 

Biological Influences on Mental Health and Mental Illness 52 

The Genetics of Behavior and Mental Illness 52 

Infectious Influences 54 

PANDAS 55 



Contents, continued 



Psychosocial Influences on Mental Health and Mental Illness 55 

Psychodynamic Theories 55 

Behaviorism and Social Learning Theory 56 

The Integrative Science of Mental Illness and Health 57 

Overview of Development, Temperament, and Risk Factors 57 

Physical Development 58 

Theories of Psychological Development 59 

Piaget: Cognitive Developmental Theory 59 

Erik Erikson: Psychoanalytic Developmental Theory 59 

John Bowlby: Attachment Theory of Development 60 

Nature and Nurture: The Ultimate Synthesis 60 

Overview of Prevention 62 

Definitions of Prevention 62 

Risk Factors and Protective Factors 63 

Overview of Treatment 64 

Introduction to Range of Treatments 64 

Psychotherapy 65 

Psychodynamic Therapy 66 

Behavior Therapy 66 

Humanistic Therapy 67 

Pharmacological Therapies 68 

Mechanisms of Action 68 

Complementary and Alternative Treatment 70 

Issues in Treatment 70 

Placebo Response 70 

Benefits and Risks 71 

Gap Between Efficacy and Effectiveness 72 

Barriers to Seeking Help 72 

Overview of Mental Health Services 73 

Overall Patterns of Use 75 

History of Mental Health Services 75 



Contents, continued 



Overview of Cultural Diversity and Mental Health Services 80 

Introduction to Cultural Diversity and Demographics 81 

Coping Styles 82 

Family and Community as Resources 83 

Epidemiology and Utilization of Services 84 

African Americans 84 

Asian Americans/Pacific Islanders 85 

Hispanic Americans 86 

Native Americans 86 

Barriers to the Receipt of Treatment 86 

Help-Seeking Behavior 86 

Mistrust 86 

Stigma 87 

Cost 87 

Clinician Bias 88 

Improving Treatment for Minority Groups 88 

Ethnopsychopharmacology 88 

Minority-Oriented Services 89 

Cultural Competence 90 

Rural Mental Health Services 92 

Overview of Consumer and Family Movements 92 

Origins and Goals of Consumer Groups 93 

Self-Help Groups 94 

Accomplishments of Consumer Organizations 95 

Family Advocacy 96 

Overview of Recovery 97 

Introduction and Definitions 97 

Impact of the Recovery Concept 98 

Conclusions 100 

Mental Health and Mental Illness Across the Lifespan 102 

References 104 



Chapter 2 



The Fundamentals of Mental Health 

AND Mental Illness 



Avast body of research on mental health and, to an 
even greater extent, on mental illness constitutes 
the foundation of this Surgeon General's report. To 
understand and better appreciate the content of the 
chapters that follow, readers outside the mental health 
field may desire some background information. Thus, 
this chapter furnishes a "primer" on topics that the 
report addresses. 

The chapter begins with an overview of research 
under way today that is focused on the neuroscience of 
mental health. Modem integrative neuroscience offers 
a means of linking research on broad "systems level" 
aspects of brain function with the remarkably detailed 
tools and findings of molecular biology. The report 
begins with a discussion of the brain because it is 
central to what makes us human and provides an 
understanding of mental health and mental illness. All 
of human behavior is mediated by the brain. Consider, 
for example, a memory that most people have from 
childhood — that of learning to ride a bicycle with the 
help of a parent or friend. The fear of falling, the 
anxiety of lack of control, the reassurances of a loved 
one, and the final liberating experience of mastery and 
a newly extended universe create an unforgettable 
combination. For some, the memories are not good 
ones: falling and being chased by dogs have left marks 
of anxiety and fear that may last a lifetime. Science is 
revealing how the skill learning, emotional overtones, 
and memories of such experiences are put together 
physically in the brain. The brain and mind are two 
sides of the same coin. Mind is not possible without the 
remarkable physical complexity that is built into the 
brain, but, in addition, the physical complexity of the 



brain is useless without the sculpting that environment, 
experience, and thought itself provides. Thus the brain 
is now known to be physically shaped by contributions 
from our genes and our experience, working together. 
This strengthens the view that mental disorders are both 
caused and can be treated by biological and experiential 
processes, working together. This understanding has 
emerged from the breathtaking progress in modem 
neuroscience that has begun to integrate knowledge 
from biological and behavioral sciences. 

An overview of mental illness follows the section 
on modern integrative brain science. The section 
highlights topics including symptoms, diagnosis, 
epidemiology (i.e., research having to do with the 
distribution and determinants of mental disorders in 
population groups, including various racial and ethnic 
minority groups), and cost, all of which are discussed 
in greater and more pointed detail in the chapters that 
follow. Etiology is the study of the origins and causes 
of disease, and that section reviews research that is 
seeking to define, with ever greater precision, the 
causes of mental disorders. As will be seen, etiology 
research examines fundamental biological, behavioral, 
and sociocultural processes, as well as a necessarily 
broad array of life events. The section on development 
of temperament reveals how mental health science has 
attempted over much of the past century to understand 
how biological, psychological, and sociocultural factors 
meld in health as well as in illness. The chapter then 
reviews research approaches to the prevention and 
treatment of mental disorders and provides an overview 
of mental health services and their delivery. Final 
sections cover the growing influence on the mental 



31 



Mental Health: A Report of the Surgeon General 



health field of the need for attention to cultural 
diversity, the importance of the consumer movement, 
and new optimism about recovery from mental 
illness — that is, the possibility of recovering one's life. 

The Neuroscience of Mental Health^ 

Complexity of the Brain I: Structural 

As befits the organ of the mind, the human brain is the 
most complex structure ever investigated by our 
science. The brain contains approximately 100 biUion 
nerve cells, or neurons, and many more supporting 
cells, or glia. In and of themselves, the number of cells 



in this 3 -pound organ reveal little of its complexity. Yet 
most organs in the body are composed of only a 
handful of cell types; the brain, in contrast, has literally 
thousands of different kinds of neurons, each distinct in 
terms of its chemistry, shape, and connections 
(Figure 2-1 depicts the structural variety of neurons). 
To illustrate, one careful, recent investigation of a kind 
of intemeuron that is a small local circuit neuron in the 
retina, called the amacrine cell, found no less than 23 
identifiable types. 

But this is only the beginning of the brain's 
complexity. 



Figure 2-1. Structural variety of neurons 



PYRAMIDAL CELL 




PURKINJE CELL 




INFERIOR 
OLIVARY 
NUCLEUS 
NEURON 



SMALL 

GELATiNOSA 

CELL 



SPINDLE- 
SHAPED CELL 
(SUBSTANTIA 
GELATINOSA) 




Source: Fischbach, 1992, p. 53. (Permission granted: Patricia J. Wynne. 



' Special thanks to Steven E. Hyman, M.D., Director, National Institute of Mental Health, and Gerald D. Fischbach, M.D., Director, 
National Institute of Neurological Diseases and Stroke, for their contributions to this section. 



32 



The Fundamentals of Mental Health and Mental Illness 



The workings of the brain depend on the ability of 
nerve cells to communicate with each other. 
Communication occurs at small, specialized structures 
called synapses. The synapse typically has two parts. 
One is a specialized presynaptic structure on a terminal 
portion of the sending neuron that contains packets of 
signalling chemicals, or neurotransmitters. The second 
is a postsynaptic structure on the dendrites of the 
receiving neuron that has receptors for the 
neurotransmitter molecules. 

The typical neuron has a cell body, which contains 
the genetic material, and much of the cell's energy- 
producing machinery. Emanating from the cell body are 
dendrites, branches that are the most important 
receptive surface of the cell for communication. The 
dendrites of neurons can assume a great many shapes 
and sizes, all relevant to the way in which incoming 
messages are processed. The output of neurons is 
carried along what is usually a single branch called the 
axon. It is down this part of the neuron that signals are 
transmitted out to the next neuron. At its end, the axon 
may branch into many terminals. (Figure 2-2.) 

The usual form of communication involves 
electrical signals that travel within neurons, giving rise 
to chemical signals that diffuse, or cross, synapses, 
which in turn give rise to new electrical signals in the 
postsynaptic neuron. Each neuron, on average, makes 
more than 1,000 synaptic connections with other 
neurons. One type of cell — a Purkinje cell — may make 
between 100,000 and 200,000 connections with other 
neurons. In aggregate, there may be between 100 
trillion and a quadrillion synapses in the brain. These 
synapses are far from random. Within each region of 
the brain, there is an exquisite architecture consisting 
of layers and other anatomic substructures in which 
synaptic connections are formed. Ultimately, the 
pattern of synaptic connections gives rise to what are 
called circuits in the brain. At the integrative level, 
large- and small-scale circuits are the substrates of 
behavior and of mental life. One of the most awe- 
inspiring mysteries of brain science is how neuronal 
activity within circuits gives rise to behavior and, even, 
consciousness. 



The complexity of the brain is such that a single 
neuron may be part of more than one circuit. The 
organization of circuits in the brain reveals that the 
brain is a massively parallel, distributed information 
processor. For example, the circuits involved in vision 
receive information from the retina. After initial 
processing, these circuits analyze information into 
different streams, so that there is one stream of 
information describing what the visual object is, and 
another stream is concerned with where the object is in 
space. The information stream having to do with the 
identity of the object is actually broken down into 
several more refined parallel streams. One, for 
example, analyzes shape while another analyzes color. 
Ultimately, the visual world is resynthesized with 
information about the tactile world, and the auditory 
world, with information from memory, and with 
emotional coloration. The massively parallel design is 
a great pattern recognizer and very tolerant of failure in 
individual elements. This is why a brain of neurons is 
still a better and longer-lasting information processor 
than a computer. 

The specific connectivity of circuits is, to some 
degree, stereotyped, or set in expected patterns within 
the brain, leading to the notion that certain places in the 
brain are specialized for certain functions (Figure 2-3). 
Thus, the cerebral cortex, the mantle of neurons with its 
enormous surface area increased by outpouchings, 
called gyri, and indentations, called sulci, can be 
functionally subdivided. The back portion of the 
cerebral cortex (i.e., the occipital lobe), for example, is 
involved in the initial stages of visual processing. Just 
behind the central sulcus is the part of the cerebral 
cortex involved in the processing of tactile information 
(i.e., parietal lobe). Just in front of the central sulcus is 
a part of the cerebral cortex involved in motor behavior 
(frontal lobe). In the front of the brain is a region called 
the prefrontal cortex, which is involved with some of 
the highest integrated functions of the human being, 
including the ability to plan and to integrate cognitive 
and emotional streams of information. 

Beneath the cortex are enormous numbers of axons 
sheathed in the insulating substance, myelin. This sub- 



33 



Mental Health: A Report of the Surgeon General 



Figure 2-2. How neurons communicate 



ACTION 
POTENTIAL 



||= --- = -# = 




ION 
CMANNP 



Source: Fischbach, 1992, p. 52. (Permission granted: Tomo Narasiiima.) 



34 



The Fundamentals of Mental Health and Mental Illness 



Figure 2-3. The brain: Organ of the mind 



MCTOR CORTEX 



SOMATOSENSORY 
CORTEX 



CINGULATE GYRUS OF LIMBIC CORTEX 
FORNIX 



PREFRONTAL 
CORTEX 



BASAL 
GANGUA 



EYE 



RETINA 




OPTIC 
NERVE 



HYPOTHALAMUS 

HIPPOCAMPUS 



RTUITARY GLAND 

OPTIC TRACT 



PRIMARY 
_ VISUAL 
CORTEX 

THALAMUS 



SUPERIOR 
COLLICULUS 



LATERAL 

GENICULATE 
NUCLEUS 



LOCUS 
COERULEUS 



CEREBELLUM 



*«DULLA 



SPINAL CORD 



PROhfTAL 



TEfcff'OfiAL 




LATERAL VIEW 



RARIETAt 




MIDSAGJTTAL VIEW 



Source: Fischbach, 1992, p. 51. (Permission granted: Carol Donner.) 



cortical "white matter," so named because of its 
appearance on freshly cut brain sections, surrounds 
deep aggregations of neurons, or "gray matter," which, 
like the cortex, appears gray because of the presence of 
neuronal cell bodies. It is within this gray matter that 



the brain processes information. The white matter is 
akin to wiring that conveys information from one 
region to another. Gray matter regions include the basal 
ganglia, the part of the brain that is involved in the 
initiation of motion and thus profoundly affected in 



35 



Mental Health: A Report of the Surgeon General 



Parkinson's disease, but that is also involved in the 
integration of motivational states and, thus, a substrate 
of addictive disorders. Other important gray matter 
structures in the brain include the amygdala and the 
hippocampus. The amygdala is involved in the 
assignment of emotional meaning to events and objects, 
and it appears to play a special role in aversive, or 
negative, emotions such as fear. The hippocampus 
includes, among its many functions, responsibility for 
initially encoding and consolidating explicit or episodic 
memories of persons, places, and things. 

hi summary, the organization of the brain at the 
cellular level involves many thousands of distinct kinds 
of neurons. At a higher integrative level, these neurons 
form circuits for information processing determined by 
their patterns of synaptic connections. The organization 
of these parallel distributed circuits results in the 
specialization of different geographic regions of the 
brain for different functions. It is important to state at 
this point, hovi^ever, that, especially in younger 
individuals, damage to a particular brain region may 
yield adaptations that permit circuits spared the damage 
and, therefore, other regions of the brain, to pick up 
some of the functions that would otherwise have been 
lost. 

Complexity of the Brain II: Neurochemical 

Superimposed on this breathtaking structural 
complexity is the chemical complexity of the brain. As 
described above, electrical signals within neurons are 
converted at synapses into chemical signals which then 
elicit electrical signals on the other side of the synapse. 
These chemical signals are molecules called 
neurotransmitters. There are two major kinds of 
molecules that serve the function of neurotransmitters: 
small molecules, some quite well known, with names 
such as dopamine, serotonin, or norepinephrine, and 
larger molecules, which are essentially protein chains, 
called peptides. These include the endogenous opiates. 
Substance P, and corticotropin releasing factor (CRF), 
among others. All told, there appear to be more than 
100 different neurotransmitters in the brain (Table 2-1 
contains a selected list). 



A neurotransmitter can elicit a biological effect in 
the postsynaptic neuron by binding to a protein called 
a neurotransmitter receptor. Its job is to pass the 
information contained in the neurotransmitter message 
from the synapse to the inside of the receiving cell. It 
appears that almost every known neurotransmitter has 

Table 2-1. Selected neurotransmitters important in 
psychopharmacology 



Excitatory amino acid 

Glutamate 

Inhibitory amino acids 

Gamma aminobutyric acid 
Glycine 

Monoamines and related neurotransmitters 

Norepinephrine 

Dopamine 

Serotonin 

Histamine 

Acetylcholine (quarternary amine) 

Purine 

Adenosine 

Neuropeptides 
Opioids 

Enkephalins 

Beta-endorphin 

Dynorphin 

Tachyliinin 

Substance P 

Hypothalamic-releasing factors 

Corticotropin-releasing hormone 



more than one different kind of receptor that can confer 
rather different signals on the receiving neuron. 
Dopamine has 5 known neurotransmitter receptors; 
serotonin has at least 14. 

Although there are many kinds of receptors with 
many different signaling functions, we can divide most 
neurotransmitter receptors into two general classes. 
One class of neurotransmitter receptor is called a 
ligand-gated channel, where "ligand" simply means a 



36 



The Fundamentals of Mental Health and Mental Illness 



molecule (i.e., a neurotransmitter) that binds to a 
receptor. When neurotransmitters interact with this 
kind of receptor, a pore within the receptor molecule 
itself is opened and positive or negative charges enter 
the cell. The entry of positive charge may activate 
additional ion channels that allow more positive charge 
to enter. At a certain threshold, this causes a cell to fire 
an action potential — an electrical event that leads 
ultimately to the release of neurotransmitter. By 
definition, therefore, receptors that admit positive 
charge are excitatory neurotransmitter receptors. The 
classic excitatory neurotransmitter receptors in the 
brain utilize the excitatory amino acids glutamate and, 
to a lesser degree, aspartate as neurotransmitters. 
Conversely, inhibitory neurotransmitters act by 
permitting negative charges into the cell, taking the cell 
farther away from firing. The classic inhibitory 
neurotransmitters in the brain are the amino acids 
gamma amino butyric acid, or GABA, and, to a lesser 
degree, glycine. 

Most of the other neurotransmitters in the brain, 
such as dopamine, serotonin, and norepinephrine, and 
all of the many neuropeptides constitute the second 
major class. These are neither precisely excitatory nor 
inhibitory but rather act to produce complex 
biochemical changes in the receiving cell. Their 
receptors do not contain intrinsic ion pores but rather 
interact with signaling proteins, called "G proteins" 
found inside the cell membrane. These receptors thus 
are called G protein-linked receptors. The details are 
less important than understanding the general scheme. 
Stimulation of G protein-linked receptors alters the way 
in which receiving neurons can process subsequent 
signals from glutamate or GABA. To use a metaphor of 
a musical instrument, if glutamate, the excitatory 
neurotransmitter, is puffing wind into a flute or 
clarinet, it is the modulatory neurotransmitters such as 
dopamine or serotonin that might be seen as playing the 
keys and, thus, altering the melody via G protein-hnked 
receptors. 

The architecture of these systems drives home this 
point. The precise brain circuits that carry specific 
information about the world and that are involved in 



precise point-to-point communication within the brain 
use excitatory or inhibitory neurotransmission. 
Examples of such circuits, which are massively 
parallel, can be found in the visual and auditory cortex. 
Overlying this pattern of precise, rapid (timing in the 
range of milliseconds) neurotransmission are the 
modulatory systems in the brain that use 
norepinephrine, serotonin, and dopamine. In each case, 
the neurotransmitter in question is made by a very 
small number of nerve cells clustered in a Hmited 
number of areas in the brain. Of the hundred billion 
neurons in the brain, only about 500,000, for example, 
make dopamine — that is, for every 200,000 cells in the 
brain, only one makes dopamine. Even fewer make 
norepinephrine. The cell bodies of the dopamine 
neurons are clustered in a few brain regions, most 
importantly, regions deep in the brain, in the midbrain, 
called the substantia nigra, and the ventral tegmental 
area. Norepinephrine neurons are made in the nucleus 
locus coeruleus even farther down in the brain stem in 
a structure called the pons. Serotonin is made by a 
somewhat larger number of nuclei but, still, not by 
many cells. Nuclei called the raphe nuclei spread along 
the brain stem. While each of these neurotransmitters 
is made by a small number of neurons with clustered 
cell bodies, each sends its axons branching throughout 
the brain, so that in each case a very small number of 
neurons, which largely appear to fire in unison when 
excited, influence almost the entire brain. This is not 
the picture of systems that are communicating precise 
bits of information about the world but rather are 
intrinsic modulatory systems that act via other G 
protein-linked receptors to alter the overall 
responsiveness of the brain. These neurotransmitters 
are responsible for brain states such as degree of 
arousal, ability to pay attention, and for putting 
emotional color or significance on top of cold cognitive 
information provided by precise glutaminergic circuits. 
It is no wonder that these modulatory neurotransmitters 
and their receptors are critical targets of medications 
used to treat mental disorders — for example, the 
antidepressant and antipsychotic drugs — and also are 
the targets of drugs of abuse. 



37 



Mental Health: A Report of the Surgeon General 



Complexity of the Brain III: Plasticity 

The preceding paragraphs have illustrated the chemical 
and anatomic structure of the brain and, in so doing, 
provided some picture of its complexity as well as 
some picture of its function. The crowning complexity 
of the brain, however, is that it is not static. The brain 
is always changing. People learn so much and have so 
many distinct types of memory: conscious, episodic 
memory of the sort that is encoded initially in the 
hippocampus; memory of motor programs or 
procedures that are encoded in the striatum; emotional 
memories that can initiate physiologic and behaviorally 
adaptive repertoires encoded, for example, in the 
amygdala; and many other kinds. Every time a person 
learns something new, whether it is conscious or 
unconscious, that experience alters the structure of the 
brain. Thus, neurotransmission in itself not only 
contains current information but alters subsequent 
neurotransmission if it occurs with the right intensity 
and the right pattern. Experience that is salient enough 
to cause memory creates new synaptic connections, 
prunes away old ones, and strengthens or weakens 
existing ones. Similarly, experiences as diverse as 
stress, substance abuse, or disease can kill neurons, and 
current data suggest that new neurons continue to 
develop even in adult brains, where they help to 
incorporate new memories. The end result is that 
information is now routed over an altered circuit. Many 
of these changes are long-lived, even permanent. It is in 
this way that a person can look back 10 or 20 or 50 
years and remember family, a home or school room, or 
friends. The general theme is that to really understand 
the kind of memory — indeed, any brain function — one 
must think at least at two levels: one, the level of 
molecular and cellular alterations that are responsible 
for remodeling synapses, and, two, the level of 
information content and behavior which circuits and 
synapses serve. 

To summarize this section, scientists are truly 
beginning to learn about the structure and function of 
the brain. Its awe-inspiring complexity is fully 
consistent with the fact that it supports all behavior and 
mental life. Implied in the foregoing, is the fact that 
brains are built not only by genes — and again, it is the 



lion's share of the 80,000 or so human genes that are 
involved in building a structure so complex as the 
brain. Genes are not by themselves the whole story. 
Brains are built and changed through life through the 
interaction of genes with environment, including 
experience. It is true that a set of genes might create 
repetitive multiples of one type of unit, yet the brain 
appears far more complex than that. It stands to reason 
that if 50,000 or 60,000 genes are involved in building 
a brain that may have 100 trillion or a quadrillion 
synapses, additional information is needed, and that 
information comes from the environment. It is this 
fundamental realization that is beginning to permit an 
understanding of how treatment of mental disorders 
works — whether in the form of a somatic intervention 
such as a medication, or a psychological "talk" 
therapy — by actually changing the brain. 

Imaging the Brain 

There are many exciting developments in brain science. 
Of great relevance to the study of mental function and 
mental illness is the ability to image the activity of the 
living human brain with technologies developed in 
recent decades, such as positron emission tomography 
scanning or functional magnetic resonance imaging. 
Such approaches can exploit surrogates of neuronal 
firing such as blood flow and blood oxygenation to 
provide maps of activity. As science learns more about 
brain circuitry and learns more from cognitive and 
affective neuroscience about how to activate and 
examine the function of particular brain circuits, 
differences between health and illness in the function 
of particular circuits certainly will become evident. We 
will be able to see the action of psychotropic drugs and, 
perhaps most exciting, we will be able to see the impact 
of that special kind of learning called psychotherapy, 
which works after all because it works on the brain. 

Different brain chemicals, brain receptors, and 
brain structures will come up in the discussion of 
particular illnesses throughout this document. This 
section is meant to provide a panoramic, not a detailed, 
introduction and also to provide certain overarching 
lessons. When something is referred to as biological or 
brain-based, that is not shorthand for saying it is 



38 



The Fundamentals of Mental Health and Mental Illness 



genetic and, thus, predetermined; similarly, references 
to "psychological" or even "social" phenomena do not 
exclude biological processes. The brain is the great 
integrator, bringing together genes and environment. 
The study of the brain requires reducing problems 
initially to bite-sized bits that will allow investigators 
to learn something, but ultimately, the agenda of 
neuroscience is not reductionist; the goal is to 
understand behavior, not to put blinders on and try to 
explain it away. As the foregoing discussion illustrates, 
the brain also is complex. Thus, having a disease that 
affects one or even many critical circuits does not 
overthrow, except in extreme cases, such as advanced 
Alzheimer's disease, all aspects of a person. Typically, 
people retain their personality and, in most cases, their 
ability to take responsibility for themselves. 

In retrospect, early biological models of the mind 
seem impoverished and deterministic — ^for example, 
models that held that "levels" of a neurotransmitter 
such as serotonin in the brain were the principal 
influence on whether one was depressed or aggressive. 
Neuroscience is far beyond that now, working to 
integrate information coming "bottom-up" from genes 
and molecules and cells, with information flowing 
"top-down" from interactions with the environment and 
experience to the internal workings of the mind and its 
neuronal circuits. Ultimately, however, the goal is not 
only human self-understanding, hi knowing eventually 
precisely what goes wrong in what circuits and what 
synapses and with what chemical signals, the hope is to 
develop treatments with greater effectiveness and with 
fewer side effects. Indeed, as the following chapters 
indicate, the hope is for cures and ultimately for 
prevention. There is every reason to hope that as our 
science progresses, we will achieve those goals. 

Overview of Mental Illness 

Mental illness is a term rooted in history that refers 
collectively to all of the diagnosable mental disorders. 
Mental disorders are characterized by abnormalities in 
cognition, emotion or mood, or the highest integrative 
aspects of behavior, such as social interactions or 
planning of future activities. These mental functions 
are all mediated by the brain. It is, in fact, a core tenet 



of modem science that behavior and our subjective 
mental lives reflect the overall workings of the brain. 
Thus, symptoms related to behavior or our mental lives 
clearly reflect variations or abnormalities in brain 
function. On the more difficult side of the ledger are 
the terms disorder, disease, or illness. There can be no 
doubt that an individual with schizophrenia is seriously 
ill, but for other mental disorders such as depression or 
attention-deficit/hyperactivity disorder, the signs and 
symptoms exist on a continuum and there is no bright 
line separating health from illness, distress from 
disease. Moreover, the manifestations of mental 
disorders vary with age, gender, race, and culture. The 
thresholds of mental illness or disorder have, indeed, 
been set by convention, but the fact is that this gray 
zone is no different from any other area of medicine. 
Ten years ago a serum cholesterol of 200 was 
considered normal. Today, this same number alarms 
some physicians and may lead to treatment. Perhaps 
every adult in the United States has some 
atherosclerosis, but at what point does this move along 
a continuum from normal into the realm of illness? 
Ultimately, the dividing line has to do with severity of 
symptoms, duration, and functional impairment. 

Despite the existence of a gray zone between health 
and illness, science can study the mechanisms by which 
illness occurs. Indeed, understanding mood regulation 
and its abnormalities, for example, proceeds 
independently from any set of diagnostic clinical 
criteria. Family studies, molecular genetics strategies, 
epidemiology, and the tools of clinical investigation 
tailored to specific populations are being used to 
investigate the mechanisms of mental illness. Specific 
manifestations of mental illness will be covered in 
succeeding pages. 

This overview of mental illness focuses on those 
features of the disease process that are most common 
and characteristic of these disorders. The chapters that 
follow will present specific details about major 
categories of mental disorders that occur across the life 
span. The purpose here is to provide a framework upon 
which subsequent discussions of specific disorders can 
rest. The section leads with a descriptive overview of 
the cardinal manifestations, signs, and symptoms of 



39 



Mental Health: A Report of the Surgeon General 



mental disorders. It then describes how mental 
disorders are diagnosed and classified and provides an 
overview of the epidemiology and societal burden of 
mental disorders. 

Manifestations of Mental Illness 

Persons suffering from any of the severe mental 
disorders present with a variety of symptoms that may 
include inappropriate anxiety, disturbances of thought 
and perception, dysregulation of mood, and cognitive 
dysfunction. Many of these symptoms may be 
relatively specific to a particular diagnosis or cultural 
influence. For example, disturbances of thought and 
perception (psychosis) are most commonly associated 
with schizophrenia. Similarly, severe disturbances in 
expression of affect and regulation of mood are most 
commonly seen in depression and bipolar disorder. 
However, it is not uncommon to see psychotic 
symptoms in patients diagnosed with mood disorders or 
to see mood-related symptoms in patients diagnosed 
with schizophrenia. Symptoms associated with mood, 
anxiety, thought process, or cognition may occur in any 
patient at some point during his or her illness. 

Anxiety 

Anxiety is one of the most readily accessible and easily 
understood of the major symptoms of mental disorders. 
Each of us encounters anxiety in many forms 
throughout the course of our routine activities. It may 
often take the concrete form of intense fear experienced 
in response to an immediately threatening experience 
such as narrowly avoiding a traffic accident. 
Experiences like this are typically accompanied by 
strong emotional responses of fear and dread as well as 
physical signs of anxiety such as rapid heart beat and 
perspiration. Some of the more common signs and 
symptoms of anxiety are listed in Table 2-2. Anxiety is 
aroused most intensely by immediate threats to one's 
safety, but it also occurs commonly in response to 
dangers that are relatively remote or abstract. Intense 
anxiety may also result from situations that one can 
only vaguely imagine or anticipate. 

Anxiety has evolved as a vitally important 
physiological response to dangerous situations that pre- 



Table 2-2. Common signs of acute anxiety 



Feelings of fear or dread 

Trembling, restlessness, and muscle tension 

Rapid heart rate 

Lightheadedness or dizziness 

Perspiration 

Cold hands/feet 

Shortness of breath 



pares one to evade or confront a threat in the 
environment. The appropriate regulation of anxiety is 
critical to the survival of virtually every higher 
organism in every environment. However, the 
mechanisms that regulate anxiety may break down in a 
wide variety of circumstances, leading to excessive or 
inappropriate expression of anxiety. Specific examples 
include phobias, panic attacks, and generalized anxiety. 
In phobias, high-level anxiety is aroused by specific 
situations or objects that may range from concrete 
entities such as snakes, to complex circumstances such 
as social interactions or public speaking. Panic attacks 
are brief and very intense episodes of anxiety that often 
occur without a precipitating event or stimulus. 
Generalized anxiety represents a more diffuse and 
nonspecific kind of anxiety that is most often 
experienced as excessive worrying, restlessness, and 
tension occurring with a chronic and sustained pattern. 
In each case, an anxiety disorder may be said to exist if 
the anxiety experienced is disproportionate to the 
circumstance, is difficult for the individual to control, 
or interferes with normal functioning. 

In addition to these common manifestations of 
anxiety, obsessive-compulsive disorder and post- 
traumatic stress disorder are generally believed to be 
related to the anxiety disorders. The specific clinical 
features of these disorders will be described more fully 
in the following chapters; however, their relationship to 
anxiety warrants mention in the present context. In the 
case of obsessive-compulsive disorder, individuals 
experience a high level of anxiety that drives their 
obsessional thinking or compulsive behaviors. When 
such an individual fails to carry out a repetitive 



40 



The Fundamentals of Mental Health and Mental Illness 



behavior such as hand washing or checking, there is an 
experience of severe anxiety. Thus while the outward 
manifestations of obsessive-compulsive disorder may 
seem to be related to other anxiety disorders, there 
appears to be a strong component of abnormal 
regulation of anxiety underlying this disorder. Post- 
traumatic stress disorder is produced by an intense and 
overwhelmingly fearful event that is often life- 
threatening in nature. The characteristic symptoms that 
result from such a traumatic event include the persistent 
reexperience of the event in dreams and memories, 
persistent avoidance of stimuU associated with the 
event, and increased arousal. 

Psychosis 

Disturbances of perception and thought process fall 
into a broad category of symptoms referred to as 
psychosis. The threshold for determining whether 
thought is impaired varies somewhat with the cultural 
context. Like anxiety, psychotic symptoms may occur 
in a wide variety of mental disorders. They are most 
characteristically associated with schizophrenia, but 
psychotic symptoms can also occur in severe mood 
disorders. 

One of the most common groups of symptoms that 
result from disordered processing and interpretation of 
sensory information are the hallucinations. 
Hallucinations are said to occur when an individual 
experiences a sensory impression that has no basis in 
reality. This impression could involve any of the 
sensory modalities. Thus hallucinations may be 
auditory, olfactory, gustatory, kinesthetic, tactile, or 
visual. For example, auditory hallucinations frequently 
involve the impression that one is hearing a voice. In 
each case, the sensory impression is falsely experienced 
as real. 

A more complex group of symptoms resulting from 
disordered interpretation of information consists of 
delusions. A delusion is a false belief that an individual 
holds despite evidence to the contrary. A common 
example is paranoia, in which a person has delusional 
beliefs that others are trying to harm him or her. 
Attempts to persuade the person that these beliefs are 



unfounded typically fail and may even result in the 
further entrenchment of the beliefs. 

Hallucinations and delusions are among the most 
commonly observed psychotic symptoms. A list of 
other symptoms seen in psychotic illnesses such as 
schizophrenia appears in Table 2-3. Symptoms of 
schizophrenia are divided into two broad classes: 
positive symptoms and negative symptoms. Positive 
symptoms generally involve the experience of 
something in consciousness that should not 
normally be present. For example, hallucinations 
and delusions represent perceptions or beliefs that 
should not normally be experienced. In addition to 
hallucinations and delusions, patients with 
psychotic disorders such as schizophrenia fre- 
quently have marked disturbances in the logical 
process of their thoughts. Specifically, psychotic 
thought processes are characteristically loose, 
disorganized, illogical, or bizarre. These 
disturbances in thought process frequently produce 
observable patterns of behavior that are also 
disorganized and bizarre. The severe disturbances 
of thought content and process that comprise the 
positive symptoms often are the most recognizable 
and striking features of psychotic disorders such as 
schizophrenia or manic depressive illness. 



Table 2-3. Common manifestations of 
schizophrenia 


Positive Symptoms 

• Hallucinations 
Delusions 

• Disorganized thoughts and behaviors 
Loose or illogical thoughts 

• Agitation 

Negative Symptoms 
Flat or blunted affect 

• Concrete thoughts 

Anhedonia (inability to experience pleasure) 

• Poor motivation, spontaneity, and initiative 



However, in addition to positive symptoms, 
patients with schizophrenia and other psychoses 



41 



Mental Health: A Report of the Surgeon General 



have been noted to exhibit major deficits in 
motivation and spontaneity that are referred to as 
negative symptoms. While positive symptoms 
represent the presence of something not normally 
experienced, negative symptoms reflect the absence 
of thoughts and behaviors that would otherwise be 
expected. Concreteness of thought represents 
impairment in the ability to think abstractly. 
Blunting of affect refers to a general reduction in 
the ability to express emotion. Motivational failure 
and inability to initiate activities represent a major 
source of long-term disability in schizophrenia. 
Anhedonia reflects a deficit in the ability to 
experience pleasure and to react appropriately to 
pleasurable situations. Positive symptoms such as 
hallucinations are responsible for much of the acute 
distress associated with schizophrenia, but negative 
symptoms appear to be responsible for much of the 
chronic and long-term disability associated with the 
disorder. 

The psychotic symptoms represent 
manifestations of disturbances in the flow, 
processing, and interpretation of information in the 
central nervous system. They seem to share an 
underlying commonality of mechanism, insofar as 
they tend to respond as a group to specific 
pharmacological interventions. However, much 
remains to be learned about the brain mechanisms 
that lead to psychosis. 

Disturbances of Mood 

Most of us have an immediate and intuitive 
understanding of the notion of mood. We readily 
comprehend what it means to feel sad or happy. 
These concepts are nonetheless very difficult to 
formulate in a scientifically precise and 
quantifiable way; the challenge is greater given the 
cultural differences that are associated with the 
expression of mood. In turn, disorders that impact 
on the regulation of mood are relatively difficult to 
define and to approach in a quantitative manner. 
Nevertheless, dysregulation of mood and the 
expression of mood, or affect, represent a major 
category among mental disorders. 



Disturbances of mood characteristically 
manifest themselves as a sustained feeling of 
sadness or sustained elevation of mood. As with 
anxiety and psychosis, disturbances of mood may 
occur in a variety of patterns associated with 
different mental disorders. The disorder most 
closely associated with persistent sadness is major 
depression, while that associated with sustained 
elevation or fluctuation of mood is bipolar disorder. 
The most common signs of these mood disorders 
are listed in Table 2-4. Along with the prevailing 
feelings of sadness or elation, disorders of mood 
are associated with a host of related symptoms that 
include disturbances in appetite, sleep patterns, 
energy level, concentration, and memory. 

Table 2-4. Common signs of mood disorders 



Symptoms Commonly Associated With 
Depression 

• Persistent sadness or despair 

• Insomnia (sometimes liypersomnia) 

• Decreased appetite 

• Psyclnomotor retardation 

• Anhedonia (inability to experience pleasure) 

• Irritability 

• Apathy, poor motivation, social withdrawal 

• Hopelessness 

• Poor self-esteem, feelings of helplessness 

Suicidal ideation 
Symptoms Commonly Associated With Mania 

• Persistently elevated or euphoric mood 

• Grandiosity (inappropriately high self-esteem) 

• Psychomotor agitation 

• Decreased sleep 

• Racing thoughts and distractibility 

• Poor judgment and impaired impulse control 
Rapid or pressured speech 



42 



The Fundamentals of Mental Health and Mental Illness 



It is not known why diverse functions such as 
sleep and appetite should be altered in disorders of 
mood. However, depression and mania are typically 
associated with characteristic changes in these 
basic functions. Mood appears to represent a 
complex group of behaviors and responses that 
undergo precise and tightly controlled regulation. 
Higher organisms that must adapt to changing 
environments depend on optimal control of basic 
functions such as sleep, appetite, sex, and physical 
activity. This regulation must adapt to diurnal and 
seasonal changes in the environment. In addition, 
more complex behaviors such as exploration, 
aggression, and social interaction must also 
undergo a similar, perhaps closely linked, 
regulation. In humans, these complex behaviors and 
their regulation are believed to be associated with 
the expression of mood. A depressed mood appears 
to reflect a kind of global damping of these 
functions, while a manic state may result from an 
excessive activation of these same functions. The 
mechanisms underlying the diverse changes 
associated with the mood disorders are largely 
unknown, but their appearance as clusters in 
specific disorders along with their collective 
response to specific therapeutics suggests a 
common mechanistic basis. 

Disturbances of Cognition 

Cognitive function refers to the general ability to 
organize, process, and recall information. Cognitive 
tasks may be subdivided into a large number of 
more specific functions depending on the nature of 
the information remembered and the circumstances 
of its recall. In addition, there are many functions 
commonly associated with cognition such as the 
ability to execute complex sequences of tasks. 
Disturbances of cognitive function may occur in a 
variety of disorders. Progressive deterioration of 
cognitive function is referred to as dementia. 
Dementia may be caused by a number of specific 
conditions including Alzheimer's disease (to be 
discussed in subsequent chapters). Impairment of 
cognitive function may also occur in other mental 



disorders such as depression. It is not uncommon to 
find profound disturbances of cognition in patients 
suffering from severe mood disturbances. More 
recently, cognitive deficits have been reported in 
schizophrenia and now have become a major new 
topic of research. Lastly, cognitive impairment 
frequently occurs in a host of chemical, metabolic, 
and infectious diseases that exert an impact on the 
brain. 

The manifestations of cognitive impairment can 
vary across an extremely wide range, depending on 
severity. Short-term memory is one of the earliest 
functions to be affected and, as severity increases, 
retrieval of more remote memories becomes more 
difficult. Attention, concentration, and higher 
intellectual functions can be impaired as the 
underlying disease process progresses. Language 
difficulties range from mild word-finding problems 
to complete inability to comprehend or use 
language. Functional impairments associated with 
cognitive deficits can markedly interfere with the 
ability to perform activities of daily living such as 
dressing and bathing. 

Other Symptoms 

Anxiety, psychosis, mood disturbances, and 
cognitive impairments are among the most common 
and disabling manifestations of mental disorders. It 
is important, however, to appreciate that mental 
disorders leave no aspect of human experience 
untouched. It is beyond the scope of the present 
chapter to detail the full spectrum of presentations 
of mental disorders. Other common manifestations 
include, for example, somatic or other physical 
symptoms and impairment of impulse control. 
Many of these issues will be touched upon in 
subsequent chapters with reference to specific 
disorders. 

Diagnosis of Mental Illness 

The foregoing discussion has suggested that the 
manifestations of mental disorders fall into a 
number of distinct categories such as anxiety, 
psychosis, mood disturbance, and cognitive 



43 



Mental Health: A Report of the Surgeon General 



deficits. These categories are broad, heterogeneous, 
and somewhat overlapping. Moreover, any 
particular patient may manifest symptoms from 
more than one of these categories. This is not 
unexpected, given the highly complex interactions 
that take place among the neurobiological and 
behavioral substrates that produce these symptoms. 
Despite these confounding difficulties, a systematic 
approach to the classification and diagnosis of 
mental illness has been developed. Diagnosis is 
essential in all areas of health for shaping treatment 
and supportive care, establishing a prognosis, and 
preventing related disability. Diagnosis also serves 
as shorthand to enhance communication, research, 
surveillance, and reimbursement. 

The diagnosis of mental disorders is often 
believed to be more difficult than diagnosis of 
somatic, or general medical, disorders, since there 
is no definitive lesion, laboratory test, or 
abnormality in brain tissue that can identify the 
illness. The diagnosis of mental disorders must rest 
with the patients' reports of the intensity and 
duration of symptoms, signs from their mental 
status examination, and clinician observation of 
their behavior including functional impairment. 
These clues are grouped together by the clinician 
into recognizable patterns known as syndromes. 
When the syndrome meets all the criteria for a 
diagnosis, it constitutes a mental disorder. Most 
mental health conditions are referred to as 
disorders, rather than as diseases, because 
diagnosis rests on clinical criteria. The term 
"disease" generally is reserved for conditions with 
known pathology (detectable physical change). The 
term "disorder," on the other hand, is reserved for 
clusters of symptoms and signs associated with 
distress and disability (i.e., impairment of 
functioning), yet whose pathology and etiology are 
unknown. 

The standard manual used for diagnosis of 
mental disorders in the United States is the 
Diagnostic and Statistical Manual of Mental 



Disorders. Most recently revised in 1994, this 
manual now is in its fourth edition (American 
Psychiatric Association, 1994, hereinafter cited in 
this report as DSM-IV). The first edition was 
published in 1952 by the American Psychiatric 
Association; subsequent revisions, which were 
made on the basis of field trials, analysis of data 
sets, and systematic reviews of the research 
literature, have sought to gain greater objectivity, 
diagnostic precision, and reliability. DSM-IV 
organizes mental disorders into 16 major diagnostic 
classes listed in Table 2-5 . For each disorder within 
a diagnostic class, DSM-IV enumerates specific 
criteria for making the diagnosis. DSM-IV also lists 
diagnostic "subtypes" for some disorders. A 
subtype is a subgroup within a diagnosis that 
confers greater specificity. DSM-IV is descriptive 
in its listing of symptoms and does not take a 
position about underlying causation. 

Table 2-5. Major Diagnostic Classes of Mental 
Disorders (DSM-IV) 



Disorders usually first diagnosed in infancy, 
childhood, or adolescence 

Delerium, dementia, and amnestic and other 
cognitive disorders 

Mental disorders due to a general medical condition 

Substance-related disorders 

Schizophrenia and other psychotic disorders 

Mood disorders 

Anxiety disorders 

Somatoform disorders 

Factitious disorders 

Dissociative disorders 

Sexual and gender identity disorders 

Eating disorders 

Sleep disorders 

Impulse-control disorders 

Adjustment disorders 

Personality disorders 



44 



The Fundamentals of Mental Health and Mental Illness 



DSM-IV and its predecessors^ represent a 
unique approach to diagnosis by a professional 
field. No other sphere of health care has created 
such an extensive compendium of all of its 
disorders with explicit diagnostic criteria. The 
World Health Organization's International 
Classification of Diseases (10th edition, 1992) is a 
valuable compendium of all diseases. Its mental 
health categories are expanded upon in DSM-IV. 
The International Classification of Diseases (ICD) 
is the official classification for mortality and 
morbidity statistics for all signatories to theU.N. 
Charter establishing the World Health 
Organization. ICD-9CM (9th edition. Clinical 
Modification, 1991) is still the official 
classification for the Health Care Financing 
Administration. 

Knowledge about diagnosis continues to 
evolve. Evolution in the diagnosis of mental 
disorders generally reflects greater understanding 
of disorders as well as the influence of social 
norms. Years ago, for instance, addiction to 
tobacco was not viewed as a disorder, but today it 
falls under the category of "Substance-Related 
Disorders." Although DSM-IV strives to cover all 
populations, it is not without limitations. The 
difficulties encountered in diagnosing mental 
disorders in children, older persons, and racial and 
ethnic minority groups are discussed later in this 
chapter and throughout this report. Diagnosis rests 
on clinician judgment about whether clients' 
symptom patterns and impairments of functioning 
meet diagnostic criteria. Cultural differences in 
emotional expression and social behavior can be 
misinterpreted as "impaired" if clinicians are not 
sensitive to the cultural context and meaning of 
exhibited symptoms, a topic discussed later in this 
chapter in Overview of Cultural Diversity and 
Mental Health Services. 



^ DSM-I (American Psychiatric Association, 1952), DSM-II 
(American Psychiatric Association, 1968), DSM-III (American 
Psychiatric Association, 1979), and DSM-III-R (American 
Psychiatric Association, 1987). 



Epidemiology of Mental Illness 

Few families in the United States are untouched by 
mental illness. Determining just how many people 
have mental illness is one of the many purposes of 
the field of epidemiology. Epidemiology is the 
study of patterns of disease in the population. 
Among the key terms of this discipline, 
encountered throughout this report, are incidence, 
which refers to new cases of a condition which 
occur during a specified period of time, and 
prevalence, which refers to cases (i.e., new and 
existing) of a condition observed at a point in time 
or during a period of time. According to current 
epidemiological estimates, at least one in five 
people has a diagnosable mental disorder during the 
course of a year (i.e., 1-year prevalence). 

Epidemiological estimates have shifted over 
time because of changes in the definitions and 
diagnosis of mental health and mental illness. In 
the early 1950s, the rates of mental illness 
estimated by epidemiologists were far higher than 
those of today. One study, for example, found 81.5 
percent of the population of Manhattan, New York, 
to have had signs and symptoms of mental distress 
(Srole, 1962). This led the authors of the study to 
conclude that mental illness was widespread. 
However, other studies began to find lower rates 
when they used more restrictive definitions that 
reflected more contemporary views about mental 
illness. Instead of classifying anyone with signs and 
symptoms as being mentally ill, this more recent 
line of epidemiological research only identified 
people as mentally ill if they had a cluster of signs 
and symptoms that, when taken together, impaired 
people's ability to function (Pasamanick, 1959; 
Weissman et al., 1978). By 1978, the President's 
Commission on Mental Health (1978) concluded 
conservatively that the annual prevalence of 
specific mental disorders in the United States was 
about 15 percent. This figure comports with recent 
estimates of the extent of mental illness in the 
population. Even as this figure has become more 
sharply delineated, the older and larger estimates 
underscore the magnitude of mental distress in the 



45 



Mental Health: A Report of the Surgeon General 



population, which this report refers to as "mental 
health problems." 

Adults 

The current prevalence estimate is that about 20 
percent of the U.S. population are affected by 
mental disorders during a given year. This estimate 
comes from two epidemiologic surveys: the 
Epidemiologic Catchment Area (ECA) study of the 
early 1980s and the National Comorbidity Survey 
(NCS) of the early 1990s. Those surveys defined 
mental illness according to the prevailing editions 
of the Diagnostic and Statistical Manual of Mental 
Disorders (i.e., DSM-III and DSM-III-R). The 
surveys estimate that during a 1-year period, 22 to 
23 percent of the U.S. adult population— or 44 
million people— have diagnosable mental disorders, 
according to reliable, established criteria. In 
general, 19 percent of the adult U.S. population 
have a mental disorder alone (in 1 year); 3 percent 
have both mental and addictive disorders; and 6 
percent have addictive disorders alone. ^ 
Consequently, about 28 to 30 percent of the 
population have either a mental or addictive 
disorder (Regieretal., 1993b; Kessleretal., 1994). 
Table 2-6 summarizes the results synthesized from 
these two large national surveys. 

Individuals with co-occurring disorders (about 
3 percent of the population in 1 year) are more 
likely to experience a chronic course and to utilize 
services than are those with either type of disorder 
alone. Clinicians, program developers, and policy- 
makers need to be aware of these high rates of 
comorbidity — about 15 percent of those with a 
mental disorder in 1 year (Regier et al., 1993a; 
Kessleretal., 1996). 

Based on data on functional impairment, it is 
estimated that 9 percent of all U.S. adults have the 
mental disorders listed in Table 2-6 and experience 
some significant functional impairment (National 



' Although addictive disorders are included as mental disorders in 
the DSM classification system, the ECA and NCS distinguish 
between addictive disorders and (all other) mental disorders. 
Epidemiologic data in this report follow that convention. 



Advisory Mental Health Council [NAMHC], 1993). 
Most (7 percent of adults) have disorders that 
persist for at least 1 year (Regier et al., 1993b; 
Regier et al., in press). A subpopulation of 5.4 
percent of adults is considered to have a "serious" 
mental illness (SMI) (Kessler et al., 1996). Serious 
mental illness is a term defined by Federal 
regulations that generally applies to mental 
disorders that interfere with some area of social 
functioning. About half of those with SMI (or 2.6 
percent of all adults) were identified as being even 
more seriously affected, that is, by having "severe 
and persistent" mental illness (SPMI) (NAMHC, 
1993; Kessler et al., 1996). This category includes 
schizophrenia, bipolar disorder, other severe forms 
of depression, panic disorder, and obsessive- 
compulsive disorder. These disorders and the 
problems faced by these special populations with 
SMI and SPMI are described further in subsequent 
chapters. Among those most severely disabled are 
the approximately 0.5 percent of the population 
who receive disability benefits for mental health- 
related reasons from the Social Security 
Administration (NAMHC, 1993). 

Children and Adolescents 

The annual prevalence of mental disorders in 
children and adolescents is not as well documented 
as that for adults. About 20 percent of children are 
estimated to have mental disorders with at least 
mild functional impairment (see Table 2-7). Federal 
regulations also define a sub-population of children 
and adolescents with more severe functional 
limitations, known as "serious emotional 
disturbance" (SED)."* Children and adolescents with 
SED number approximately 5 to 9 percent of 
children ages 9 to 17 (Friedman et al., 1996b). 



The term "serious emotional disturbance" is used in a variety of 
Federal statutes in reference to children under the age of 18 with a 
diagnosable mental health problem that severely disrupts their 
ability to function socially, academically, and emotionally. The term 
does not signify any particular diagnosis; rather, it is a legal term 
that triggers a host of mandated services to meet the needs of these 
children. 



46 



The Fundamentals of Mental Health and Mental Illness 
Table 2-6. Best estimate 1-year prevalence rates based on ECA and NCS, ages 18-54 





ECA Prevalence (%) 


NCS Prevalence (%) 


Best Estimate ** (%) 


Any Anxiety Disorder 


13.1 


18.7 


16.4 


Simple Phobia 


8.3 


8.6 


8.3 


Social Phobia 


2.0 


7.4 


2.0 


Agoraphobia 


4.9 


3.7 


4.9 


GAD 


(1.5r 


3.4 


3.4 


Panic Disorder 


1.6 


2.2 


1.6 


OCD 


2.4 


(0.9)* 


2.4 


PTSD 


(i.9r 


3.6 


3.6 


1 


Any Mood Disorder 


7.1 


11.1 


7.1 


MD Episode 


6.5 


10.1 


6.5 


Unipolar MD 


5.3 


8.9 


5.3 


Dysthymia 


1.6 


2.5 


1.6 


Bipolar 1 


1.1 


1.3 


1.1 


Bipolar II 


0.6 


0.2 


0.6 


1 


Schizophrenia 


1.3 





1.3 


Nonaffective Psychosis 


— 


0.2 


0.2 


Somatization 


0.2 


— 


0.2 


ASP 


2.1 


— 


2.1 


Anorexia Nervosa 


0.1 


— 


0.1 


Severe Cognitive 


1.2 


— 


1.2 


Impairment 








1 


Any Disorder 


19.5 


23.4 


21.0 



*Numbers in parentheses Indicate the prevalence of the disorder without any comorbidity. These rates were calculated using the NCS data for 
GAD and PTSD, and the ECA data for OCD. The rates were not used in calculating the any anxiety disorder and any disorder totals for the ECA 
and NCS columns. The unduplicated GAD and PTSD rates were added to the best estimate total for any anxiety disorder (3.3%) and any disorder 
(1.5%). 

**ln developing best-estimate 1 -year prevalence rates from the two studies, a conservative procedure was followed that had previously been used 
in an independent scientific analysis comparing these two data sets (Andrews, 1 995). For any mood disorder and any anxiety disorder, the lower 
estimate of the two surveys was selected, which for these data was the ECA. The best estimate rates for the individual mood and anxiety disorders 
were then chosen from the ECA only, in order to maintain the relationships between the individual disorders. For other disorders that were not 
covered in both surveys, the available estimate was used. 

Key to abbreviations: ECA, Epidemiologic Catchment Area; NCS, National Comorbidity Study; GAD, generalized anxiety disorder; OCD, 
obsessive-compulsive disorder; PTSD, post-traumatic stress disorder; MD, major depression; ASP, antisocial personality disorder. 

Source: D. Regier, W. Narrow, & D. Rae, personal communication, 1999 



47 



Mental Health: A Report of the Surgeon General 



Table 2-7. Children and adolescents ages 9 to 17 
with mental or addictive disorders,* 
combined MECA sample 



Prevalence (%) 


Anxiety disorders 
Mood disorders 


13.0 
6.2 


Disruptive disorders 


10.3 


Substance use disorders 


2.0 


Any disorder 


20.9 



Table 2-8. Best estimate prevalence rates based 

on Epidemiologic Catchment Area, 
age 55+ 



*Disorders include diagnosis-specific impairment and 
Ciiiid Global Assessment Scale <70 (mild global 
impairment). 

Source: Shaffer et al., 1996 

Not all mental disorders identified in childhood 
and adolescence persist into adulthood, even 
though the prevalence of mental disorders in 
children and adolescents is about the same as that 
for adults (i.e., about 20 percent of each age 
population). While some disorders do continue into 
adulthood, a substantial fraction of children and 
adolescents recover or "grow out of a disorder, 
whereas, a substantial fraction of adults develops 
mental disorders in adulthood. In short, the nature 
and distribution of mental disorders in young 
people are somewhat different from those of adults. 

Older Adults 

The annual prevalence of mental disorders among 
older adults (ages 55 years and older) is also not as 
well documented as that for younger adults. 
Estimates generated from the ECA survey indicate 
that 19.8 percent of the older adult population have 
a diagnosable mental disorder during a 1-year 
period (Table 2-8). Almost 4 percent of older adults 
have SMI, and just under 1 percent has SPMI 
(Kessler et al., 1996); these figures do not include 
individuals with severe cognitive impairments such 
as Alzheimer's disease. 

Future Directions for Epidemiology 

The epidemiology of mental disorders is somewhat 
handicapped by the difficulty of identifying a 
"case" of a mental disorder. "Case" is an 



Prevalence (%) 


Any Anxiety Disorder 


11.4 


Simple Phobia 


7.3 


Social Phobia 


1.0 


Agoraphobia 


4.1 


Panic Disorder 


0.5 


Obsessive-Compulsive 
Disorder 


1.5 


1 


Any Mood Disorder 


4.4 


Major Depressive Episode 


3.8 


Unipolar Major Depression 
Dysthymia 


3.7 
1.6 


Bipolar 1 


0.2 


Bipolar II 


0.1 


1 


Schizophrenia 


0.6 


Somatization 


0.3 


Antisocial Personality Disorder 


0.0 


Anorexia Nervosa 


0.0 


Severe Cognitive Impairment 


6.6 


1 


Any Disorder 


19.8 



Source: D. Regier, W. Narrow, & D. Rae, personal com- 
munication, 1999 

epidemiological term for someone who meets the 
criteria for a disease or disorder. It is not always 
easy to establish a threshold for a mental disorder, 
particularly in light of how common symptoms of 
mental distress are and the lack of objective, 
physical symptoms. It is sometimes difficult to 
determine when a set of symptoms rises to the level 
of a mental disorder, a problem that affects other 
areas of health (e.g., criteria for certain pain 
syndromes). In many cases, symptoms are not of 
sufficient intensity or duration to meet the criteria 
for a disorder and the threshold may vary from 
culture to culture. 

Diagnosis of mental disorders is made on the 
basis of a multidimensional assessment that takes 
into account observable signs and symptoms of 



48 



The Fundamentals of Mental Health and Mental Illness 



illness, the course and duration of illness, response 
to treatment, and degree of functional impairment. 
One problem has been that there is no clearly 
measurable threshold for functional impairments. 
Efforts are currently under way in the epidemiology 
of mental disorders to create a threshold, or agreed- 
upon minimum level of functional limitation, that 
should be required to establish a "case" (i.e., a 
clinically significant condition). Epidemiology 
reflecting the state of psychiatric nosology during 
the past two decades has focused primarily on 
symptom clusters and has not uniformly 
applied — or, at times, even measured — the level of 
dysfunction. Ongoing reanalyses of existing 
epidemiological data are expected to yield better 
understanding of the rates of mental disorder and 
dysfunction in the population. 

Another limitation of contemporary mental 
health knowledge is the lack of standard measures 
of "need for treatment," particularly those which 
are culturally appropriate. Such measures are at the 
heart of the public health approach to mental 
health. Current epidemiological estimates therefore 
cannot definitively identify those who are in need 
of treatment. Other estimates presented in Chapter 
6 indicate that some individuals with mental 
disorders are in treatment and others are not; some 
are seen in primary care settings and others in 
specialty care. In the absence of valid measures of 
need, rates of disorder estimated in epidemiological 
surveys serve as an imperfect proxy for the need for 
care and treatment (Regier et al., in press). 

Subsequent sections of this report reveal the 
population basis of our understanding of mental 
health. Where appropriate, the report discusses 
mental health and illness across the entire 
population. At other times, the focus is on care in 
specialized mental health settings, primary health 
care, schools, the criminal justice system, and even 
the streets. A mainstream public health and 
population-based perspective demands such a broad 
view of mental health and mental illness. 



Costs of Mental Illness 

The costs of mental illness are exceedingly high. 
Although the question of cost is discussed more 
fully in Chapter 6, a few of the central findings are 
presented here. The direct costs of mental health 
services in the United States in 1996 totaled $69.0 
billion. This figure represents 7.3 percent of total 
health spending. An additional $17.7 billion was 
spent on Alzheimer's disease and $12.6 billion on 
substance abuse treatment. Direct costs correspond 
to spending for treatment and rehabilitation 
nationwide. 

When economists calculate the costs of an 
illness, they also strive to identify indirect costs. 
Indirect costs can be defined in different ways, but 
here they refer to lost productivity at the 
workplace, school, and home due to premature 
death or disability. The indirect costs of mental 
illness were estimated in 1990 at $78.6 billion 
(Rice & Miller, 1996). More than 80 percent of 
these costs stemmed from disability rather than 
death because mortality from mental disorders is 
relatively low. 

Overview of Etiology 

The precise causes (etiology) of most mental 
disorders are not known. But the key word in this 
statement is precise. The precise causes of most 
mental disorders — or, indeed, of mental health — 
may not be known, but the broad forces that shape 
them are known: these are biological, psycho- 
logical, and social/cultural factors. 

What is most important to reiterate is that the 
causes of health and disease are generally viewed 
as a product of the interplay or interaction between 
biological, psychological, and sociocultural factors. 
This is true for all health and illness, including 
mental health and mental illness. For instance, 
diabetes and schizophrenia alike are viewed as the 
result of interactions between biological, 
psychological, and sociocultural influences. With 
these disorders, a biological predisposition is 
necessary but not sufficient to explain their 
occurrence (Barondes, 1993). For other disorders. 



49 



Mental Health: A Report of the Surgeon General 



a psychological or sociocultural cause may be 
necessary, but again not sufficient. 

As described in the section on modern 
neuroscience, the brain and behavior are 
inextricably linked by the plasticity of the nervous 
system. The brain is the organ of mental function; 
psychological phenomena have their origin in that 
complex organ. Psychological and sociocultural 
phenomena are represented in the brain through 
memories and learning, which involve structural 
changes in the neurons and neuronal circuits. Yet 
neuroscience does not intend to reduce all 
phenomena to neurotransmission or to reinterpret 
them in a new language of synapses, receptors, and 
circuits. Psychological and sociocultural events and 
phenomena continue to have meaning for mental 
health and mental illness. 

Much of the research that is presented in the 
remainder of this report draws on theories and 
investigations that predate the more modern view 
of integrative neuroscience. It is still meaningful, 
however, to speak of the interaction of biological 
and psychological and sociocultural factors in 
health and illness. That is where the overview of 
etiology begins — with the biopsychosocial model 
of disease, followed by an explanation of important 
terms used in the study of etiology. Then, against 
the backdrop of the introductory section on brain 
and behavior, the following sections address 
biological and psychosocial influences on mental 
health and mental illness, a separation that reflects 
the distinctive research perspectives of past 
decades. The overview of etiology draws to a close 
with a discussion of the convergence of biological 
and psychosocial approaches in the study of mental 
health and mental illness. 

Biopsychosocial Model of Disease 

The modern view that many factors interact to 
produce disease may be attributed to the seminal 
work of George L. Engel, who in 1977 put forward 
the Biopsychosocial Model of Disease (Engel, 
1977). Engel' s model is a framework, rather than a 
set of detailed hypotheses, for understanding health 



and disease. To many scientists, the model lacks 
sufficient specificity to make predictions about the 
given cause or causes of any one disorder. 
Scientists want to find out what specifically is the 
contribution of different factors (e.g., genes, 
parenting, culture, stressful events) and how they 
operate. But the purpose of the biopsychosocial 
model is to take a broad view, to assert that simply 
looking at biological factors alone — which had 
been the prevailing view of disease at the time 
Engel was writing — is not sufficient to explain 
health and illness. 

According to Engel' s model, biopsychosocial 
factors are involved in the causes, manifestation, 
course, and outcome of health and disease, 
including mental disorders. The model certainly fits 
with common experience. Few people with a 
condition such as heart disease or diabetes, for 
instance, would dispute the role of stress in 
aggravating their condition. Research bears this out 
and reveals many other relationships between stress 
and disease (Cohen & Herbert, 1996; Baum & 
Posluszny, 1999). 

One single factor in isolation — biological, 
psychological, or social — may weigh heavily or 
hardly at all, depending on the behavioral trait or 
mental disorder. That is, the relative importance or 
role of any one factor in causation often varies. For 
example, a personality trait like extroversion is 
linked strongly to genetic factors, according to 
identical twin studies (Plomin et al., 1994). 
Similarly, schizophrenia is linked strongly to 
genetic factors, also according to twin studies (see 
Chapter 4). But this does not mean that genetic 
factors completely preordain or fix the nature of the 
disorder and that psychological and social factors 
are unimportant. These social factors modify 
expression and outcome of disorders. Likewise, 
some mental disorders, such as post-traumatic 
stress disorder (PTSD), are clearly caused by 
exposure to an extremely stressful event, such as 
rape, combat, natural disaster, or concentration 
camp (Yehuda, 1999). Yet not everyone develops 
PTSD after such exposure. On average, about 9 



50 



The Fundamentals of Mental Health and Mental Illness 



percent do (Breslau et al., 1998), but estimates are 
higher for particular types of trauma. For women 
who are victims of crime, one study found the 
prevalence of PTSD in a representative sample of 
women to be 26 percent (Resnick et al., 1993). The 
likelihood of developing PTSD is related to 
pretrauma vulnerability (in the form of genetic, 
biological, and personality factors), magnitude of 
the stressful event, preparedness for the event, and 
the quality of care after the event (Shalev, 1996). 

The relative roles of biological, psychological, 
or social factors also may vary across individuals 
and across stages of the life span. In some people, 
for example, depression arises primarily as a result 
of exposure to stressful life events, whereas in 
others the foremost cause of depression is genetic 
predisposition. 

Understanding Correlation, Causation, 
and Consequences 

Any discussion of the etiology of mental health and 
mental illness needs to distinguish three key terms: 
correlation, causation, and consequences. These 
terms are often confused. All too frequently a 
biological change in the brain (a lesion) is 
purported to be the "cause" of a mental disorder, 
based on finding an association between the lesion 
and a mental disorder. The fact is that any simple 
association — or correlation — cannot and does not, 
by itself, mean causation. The lesion could be a 
correlate, a cause of, or an effect of the mental 
disorder. 

When researchers begin to tease apart etiology, 
they usually start by noticing correlations. A 
correlation is an association or linkage of two (or 
more) events. A correlation simply means that the 
events are linked in some way. Finding a 
correlation between stressful life events and 
depression would prompt more research on 
causation. Does stress cause depression? Does 
depression cause stress? Or are they both caused by 
an unidentified factor? These would be the 
questions guiding research. But, with correlational 



research, several steps are needed before causation 
can be established. 

If a correlational study shows that a stressful 
event is associated with an increased probability 
for depression and that the stress usually precedes 
depression's onset, then stress is called a "risk 
factor" for depression.^ Risk factors are biological, 
psychological, or sociocultural variables that 
increase the probability for developing a disorder 
and antedate its onset (Garmezy, 1983; Werner & 
Smith, 1992; Institute of Medicine [lOM], 1994a). 
For each mental disorder, there are likely to be 
multiple risk factors, which are woven together in 
a complex chain of causation (lOM, 1994a). Some 
risk factors may carry more weight than others, and 
the interaction of risk factors may be additive or 
synergistic. 

Establishing causation of mental health and 
mental illness is extremely difficult, as explained in 
Chapter 1. Studies in the form of randomized, 
controlled experiments provide the strongest 
evidence of causation. The problem is that 
experimental research in humans may be 
logistically, ethically, or financially impossible. 
Correlational research in humans has thus provided 
much of what is known about the etiology of mental 
disorders. Yet correlational research is not as 
strong as experimental research in permitting 
inferences about causality. The establishment of a 
cause and effect relationship requires multiple 
studies and requires judgment about the weight of 
all the evidence. Multiple correlational studies can 
be used to support causality, when, for example, 
evaluating the effectiveness of clinical treatments 
(Chambless et al., 1996). But, when studying 
etiology, correlational studies are, if possible, best 
combined with evidence of biological plausibility 



' Chapter 4 contains a fuller discussion of the relationship between 
stress and depression. In common parlance, stress refers either to the 
stressful event or to the individual's response to the event. However, 
mental health professionals distinguish the two by referring to the 
external events as the "stressor" (or stressful life event) and to the 
individual's response as the "stress response." 



51 



Mental Health: A Report of the Surgeon General 



(lOM, 1994b).^ This means that correlational 
findings should fit with biological, chemical, and 
physical findings about mechanisms of action 
relating to cause and effect. 

Biological plausibility is often established in 
animal models of disease. That is why researchers 
seek animal models in which to study causation. In 
mental health research, there are some animal 
models — such as for anxiety and hyperactivity — but 
a major problem is the difficulty of finding animal 
models that simulate what is often uniquely human 
functioning. The search for animal models, 
however, is imperative. 

Consequences are defined as the later outcomes 
of a disorder. For example, the most serious 
consequence of depression in older people is 
increased mortality from either suicide or medical 
illness (Frasure-Smith et al., 1993, 1995; Conwell, 
1996; Penninx et al., 1998). The basis for this 
relationship is not fully known. The relationship 
between depression and suicide in adolescents is 
presented in Chapter 3. 

Putting this all together, the biopsychosocial 
model holds that biological, psychological, or 
social factors may be causes, correlates, and/or 
consequences in relation to mental health and 
mental illness. A stressful life event, such as 
receiving the news of a diagnosis of cancer, offers 
a graphic example of a psychological event that 
causes immediate biological changes and later has 
psychological, biological, and social consequences. 
When a patient receives news of the cancer 
diagnosis, the brain's sensory cortex simultan- 
eously registers the information (a correlate) and 
sets in motion biological changes that cause the 
heart to pound faster. The patient may experience 
an almost immediate fear of death that may later 
escalate to anxiety or depression. This certainly has 
been established for breast cancer patients 
(Farragher, 1998). Anxiety and depression are, in 



"' Other types of information used to establish cause and effect 
relationships are the strength and consistency of the association, 
time sequence information, dose-response relationships, and 
disappearance of the effect when the cause is removed. 



this case, consequences of the cancer diagnosis,^ 
although the exact mechanisms are not understood. 
Being anxious or depressed may prompt further 
changes in behavior, such as social withdrawal. So 
there may be social consequences to the diagnosis 
as well. This example is designed to lay out some 
of the complexity of the biopsychosocial model 
applied to mental health and mental illness. 

Biological Influences on Mental Health 
and Mental Illness 

There are far-reaching biological and physical 
influences on mental health and mental illness. The 
major categories are genes, infections, physical 
trauma, nutrition, hormones, and toxins (e.g., lead). 
Examples have been noted throughout Chapter 1 
and earlier in this chapter. This section focuses on 
the first two categories — genes and infections — for 
these are among the most exciting and intensive 
areas of research relating to biological influences 
on mental health and mental illness. 

The Genetics of Behavior and Mental Illness 

That genes influence behavior, normal and 
abnormal, has long been established (Plomin et al., 
1997). Genes influence behavior across the animal 
spectrum, from the lowly fruitfly all the way to 
humans. Sorting out which genes are involved and 
determining how they influence behavior present 
the greatest challenge. Research suggests that many 
mental disorders arise in part from defects not in 
single genes, but in multiple genes. However, none 
of the genes has yet been pinpointed for common 
mental disorders (National Institute of Mental 
Health [NIMH], 1998). 

The human genome contains approximately 
80,000 genes that occupy approximately 5 percent 
of the DNA sequences of the human genome. By 
the spring of 2000, the human genome project will 
have provided an initial rough draft version of the 
entire sequence of the human genome, and in the 



' Anxiety and depression may in some cases be caused by hormonal 
changes related to the tumor itself. 



52 



The Fundamentals of Mental Health and Mental Illness 



ensuing years, gaps in the sequence will be closed, 
errors will be corrected, and the precise boundaries 
of genes will be identified. 

In parallel, clinical medicine is studying the 
aggregation of human disease in families. This 
effort includes the study of mental illness, most 
notably schizophrenia, bipolar disorder (manic 
depressive illness), early onset depression, autism, 
attention-deficit/hyperactivity disorder, anorexia 
nervosa, panic disorder, and a number of other 
mental disorders (NIMH, 1998). From studying 
how these disorders run in families, and from initial 
molecular analyses of the genomes of these 
families, we have learned that heredity — that is, 
genes — plays a role in the transmission of 
vulnerability of all the aforementioned disorders 
from generation to generation. 

But we have also learned that the transmission 
of risk is not simple. Certain human diseases such 
as Huntington's disease and cystic fibrosis result 
from the transmission of a mutation — that is, a 
deleteriously altered gene sequence — at one 
location in the human genome. In these diseases, a 
single mutation has everything to say about whether 
one will get the illness. The transmission of a trait 
due to a single gene in the human genome is called 
Mendelian transmission, after the Austrian monk, 
Gregor Mendel, who was the first to develop 
principles of modern genetics and who studied 
traits due to single genes. When a single gene 
determines the presence or absence of a disease or 
other trait, genes are rather easy to discover on the 
basis of modern methods. Indeed, for almost all 
Mendelian disorders across medicine that affect 
more than a few people, the genes already have 
been identified. 

In contrast to Mendelian disorders, to our 
knowledge, all mental illnesses and all normal 
variants of behavior are genetically complex. What 
this means is that no single gene or even a 
combination of genes dictates whether someone 
will have an illness or a particular behavioral trait. 
Rather, mental illness appears to result from the 
interaction of multiple genes that confer risk, and 



this risk is converted into illness by the interaction 
of genes with environmental factors. The 
implications for science are, first, that no gene is 
equivalent to fate for mental illness. This gives us 
hope that modifiable environmental risk factors can 
eventually be identified and become targets for 
prevention efforts. In addition, we recognize that 
genes, while significant in their aggregate 
contribution to risk, may each contribute only a 
small increment, and, therefore, will be difficult to 
discover. As a result, however, of the Human 
Genome Project, we will know the sequence of 
each human gene and the common variants for each 
gene throughout the human race. With this 
information, combined with modern technologies, 
we will in the coming years identify genes that 
confer risk of specific mental illnesses. 

This information will be of the highest 
importance for several reasons. First, genes are the 
blueprints of cells. The products of genes, proteins, 
work together in pathways or in building cellular 
structures, so that finding variants within genes 
will suggest pathways that can be targets of 
opportunity for the development of new therapeutic 
interventions. Genes will also be important clues to 
what goes wrong in the brain when a disease 
occurs. For example, once we know that a certain 
gene is involved in risk of a particular mental 
illness such as schizophrenia or autism, we can ask 
at what time during the development of the brain 
that particular gene is active and in which cells and 
circuits the gene is expressed. This will give us 
clues to critical times for intervention in a disease 
process and information about what it is that goes 
wrong. Finally, genes will provide tools for those 
scientists who are searching for environmental risk 
factors. Information from genetics will tell us at 
what age environmental cofactors in risk must be 
active, and genes will help us identify 
homogeneous populations for studies of treatment 
and of prevention. 

Heritability refers to how much genetics con- 
tributes to the variation of a disease or trait in a 
population at a given point in time (Plomin et al., 



53 



Mental Health: A Report of the Surgeon General 



1997). Once a disorder is established as running in 
families, the next step is to determine its 
heritability (see below), then its mode of 
transmission, and, lastly, its location through 
genetic mapping (Lombroso et al., 1994). 

One powerful method for estimating heritability 
is through twin studies.^ Twin studies often 
compare the frequency with which identical versus 
fraternal twins display a disorder. Since identical 
twins are from the same fertilized egg, they share 
the exact genetic inheritance. Fraternal twins are 
from separate eggs and thereby share only 50 
percent of their genetic inheritance. If a disorder is 
heritable, identical twins should have a higher rate 
of concordance — the expression of the trait by both 
members of a twin pair — than fraternal twins. Such 
studies, however, do not furnish information about 
which or how many genes are involved. They just 
can be used to estimate heritability. For example, 
the heritability of bipolar disorder, according to the 
most rigorous twin study, is about 59 percent, 
although other estimates vary (NIMH, 1998). The 
heritability of schizophrenia is estimated, on the 
basis of twin studies, at a somewhat higher level 
(NIMH, 1998). 

Even with a high level of heritability, however, 
it is essential to point out that environmental 
factors (e.g., psychosocial environment, nutrition, 
health care access) can play a significant role in the 
severity and course of a disorder. 

Another point is that environmental factors may 
even protect against the disorder developing in the 
first place. Even with the relatively high heritabili- 
ty of schizophrenia, the median concordance rate 
among identical twins is 46 percent^ (NIMH, 1998), 
meaning that in over half of the cases, the second 



"* Establishing that a disorder runs in families could suggest 
environmental and/or genetic influences because families share 
genes and environment. Comparing identical versus fraternal twins 
assumes that their shared environments are about equal, thereby 
providing insight about genetic influences. Such comparisons are 
further enhanced by studies of twins (identical vs. fraternal) 
separated at birth and adopted by different families. 

' The median concordance rate for identical twins is only 14 percent 
(NIMH, 1998). 



twin does not manifest schizophrenia even though 
he or she has the same genes as the affected twin. 
This implies that environmental factors exert a 
significant role in the onset of schizophrenia. 

Infectious Influences 

It has been known since the early part of the 20th 
century that infectious agents can penetrate into the 
brain where they can cause mental disorders. A 
highly common mental disorder of unknown 
etiology at the turn of the century, termed "general 
paresis," turned out to be a late manifestation of 
syphilis. The sexually transmitted infectious 
agent — Treponema pallidum — first caused 
symptoms in reproductive organs and then, 
sometimes years later, migrated to the brain where 
it led to neurosyphilis. Neurosyphilis was manifest 
by neurological deterioration (including psychosis), 
paralysis, and later death. With the wide 
availability of penicillin after World War II, 
neurosyphilis was virtually eliminated (Barondes, 
1993). 

Neurosyphilis may be thought of as a disease of 
the past (at least in the developed world), but 
dementia associated with infection by the human 
immunodeficiency virus (HIV) is certainly not. 
HIV-associated dementia continues to encumber 
HIV-infected individuals worldwide. HIV infection 
penetrates into the brain, producing a range of 
progressive cognitive and behavioral impairments. 
Early symptoms include impaired memory and 
concentration, psychomotor slowing, and apathy. 
Later symptoms, usually appearing years after 
infection, include global impairments marked by 
mutism, incontinence, and paraplegia (Navia et al., 
1986). The prevalence of HIV-associated dementia 
varies, with estimates ranging from 15 percent to 
44 percent of patients with HIV infection (Grant et 
al., 1987; McArthur et al., 1993). The high end of 
this estimate includes patients with subtle 
neuropsychological abnormalities. What is 
remarkable about HIV-associated dementia is that 
it appears to be caused not by direct infection of 
neurons, but by infection of immune cells known as 



54 



The Fundamentals of Mental Health and Mental Illness 



macrophages that enter the brain from the blood. 
The macrophages indirectly cause dysfunction and 
death in nearby neurons by releasing soluble toxins 
(Epstein & Gendelman, 1993). 

Besides HIV-associated dementia and 
neurosyphilis, other mental disorders are caused by 
infectious agents. They include herpes simplex 
encephalitis, measles encephalomyelitis, rabies 
encephalitis, chronic meningitis, and subacute 
sclerosing panencephalitis (Kaplan & Sadock, 
1998). More recently, research has uncovered an 
infectious etiology to one form of obsessive- 
compulsive disorder, as explained below. 

PANDAS 

In the late 1980s, it was discovered that some 
children with obsessive-compulsive disorder (OCD) 
experienced a sudden onset of symptoms soon after 
a streptococcal pharyngitis (Garvey et al., 1998). 
The symptoms were classic for OCD — concerns 
about contamination, spitting compulsions, and 
extremely excessive hoarding — but the abrupt onset 
was unusual. Further study of these children led to 
the identification of a new classification of OCD 
called PANDAS. This acronym stands for pediatric 
autoimmune neuropsychiatric disorders associated 
with streptococcal infection. PANDAS are distinct 
from classic cases of OCD because of their 
episodic clinical course marked by sudden 
symptom exacerbation linked to streptococcal 
infection, among other unique features. The 
exacerbation of symptoms is correlated with a rise 
in levels of antibodies that the child produces to 
fight the strep infection. Consequently, researchers 
proposed that PANDAS are caused by antibodies 
against the strep infection that also manage to 
attack the basal ganglia region of the child's brain 
(Garvey et al., 1998). In other words, the strep 
infection triggers the child's immune system to 
develop antibodies, which, in turn, may attack the 
child's brain, leading to obsessive and compulsive 
behaviors. Under this proposal, the strep infection 
does not directly induce the condition; rather, it 



may do so indirectly by triggering antibody 
formation. How the antibodies are so damaging to 
a discrete region of the child's brain and how this 
attack ignites OCD-like symptoms are two of the 
fundamental questions guiding research. 

Psychosocial Influences on Mental 
Health and Mental Illness 

This chapter thus far has highlighted some of the 
psychosocial influences on mental health and 
mental illness. Stressful life events, affect (mood 
and level of arousal), personality, and gender are 
prominent psychological influences. Social 
influences include parents, socioeconomic status, 
racial, cultural, and religious background, and 
interpersonal relationships. These psychosocial 
influences, taken individually or together, are 
integrated into many chapters of this report in 
discussions of epidemiology, etiology, risk factors, 
barriers to treatment, and facilitators to recovery. 
Since these psychosocial influences are familiar 
to the general reader, detailed description of each 
is beyond the scope of this section (with the 
exception of cultural influences, which are 
discussed in the Overview of Cultural Diversity and 
Mental Health Services section). Instead, this 
section summarizes the sweeping theories of 
individual behavior and personality that inspired a 
vast body of psychosocial research: psychodynamic 
theories, behaviorism, and social learning theories. 
The therapeutic strategies that arose from these 
theories, and modifications necessary to make them 
relevant to the changing demography of the U.S. 
population, are discussed in a later section. 
Overview of Treatment. 

Psychodynamic Theories 

Psychodynamic theories of personality assert that 
behavior is the product of underlying conflicts over 
which people often have scant awareness. Sigmund 
Freud (1856-1939) was the towering proponent of 
psychoanalytic theory, the first of the 20th-century 
psychodynamic theories. Many of Freud's 



55 



Mental Health: A Report of the Surgeon General 



followers pioneered their own psychodynamic 
theories, but this section covers only 
psychoanalytic theory. A brief discussion of 
Freud's work contributes to an historical 
perspective of mental health theory and treatment 
approaches. 

Freud's theory of psychoanalysis holds two 
major assumptions: (1) that much of mental life is 
unconscious (i.e., outside awareness), and (2) that 
past experiences, especially in early childhood, 
shape how a person feels and behaves throughout 
life (Brenner, 1978). 

Freud's structural model of personality divides 
the personality into three parts — the id, the ego, 
and the superego. The id is the unconscious part 
that is the cauldron of raw drives, such as for sex or 
aggression. The ego, which has conscious and 
unconscious elements, is the rational and 
reasonable part of personality. Its role is to 
maintain contact with the outside world in order to 
help keep the individual in touch with society. As 
such, the ego mediates between the conflicting 
tendencies of the id and the superego. The latter is 
a person's conscience that develops early in life 
and is learned from parents, teachers, and others. 
Like the ego, the superego has conscious and 
unconscious elements (Brenner, 1978). 

When all three parts of the personality are in 
dynamic equilibrium, the individual is thought to 
be mentally healthy. However, according to 
psychoanalytic theory, if the ego is unable to 
mediate between the id and the superego, an 
imbalance would occur in the form of 
psychological distress and symptoms of mental 
disorders. Psychoanalytic theory views symptoms 
as important only in terms of expression of 
underlying conflicts between the parts of 
personality. The theory holds that the conflicts 
must be understood by the individual with the aid 
of the psychoanalyst who would help the person 
unearth the secrets of the unconscious. This was the 
basis for psychoanalysis as a form of treatment, as 
explained later in this chapter. 



Behaviorism and Social Learning Theory 

Behaviorism (also called learning theory) posits 
that personality is the sum of an individual's 
observable responses to the outside world 
(Feldman, 1997). As charted by J. B. Watson and 
B. F. Skinner in the early part of the 20th century, 
behaviorism stands at loggerheads with 
psychodynamic theories, which strive to understand 
underlying conflicts. Behaviorism rejects the 
existence of underlying conflicts and an 
unconscious. Rather, it focuses on observable, 
overt behaviors that are learned from the 
environment (Kazdin, 1996, 1997). Its application 
to treatment of mental problems, which is discussed 
later, is known as behavior modification. 

Learning is seen as behavior change molded by 
experience. Learning is accomplished largely 
through either classical or operant conditioning. 
Classical conditioning is grounded in the research 
of Ivan Pavlov, a Russian physiologist. It explains 
why some people react to formerly neutral stimuli 
in their environment, stimuli that previously would 
not have elicited a reaction. Pavlov's dogs, for 
example, learned to salivate merely at the sound of 
the bell, without any food in sight. Originally, the 
sound of the bell would not have elicited salvation. 
But by repeatedly pairing the sight of the food 
(which elicits salvation on its own) with the sound 
of the bell, Pavlov taught the dogs to salivate just 
to the sound of the bell by itself. 

Operant conditioning, a process described and 
coined by B. F. Skinner, is a form of learning in 
which a voluntary response is strengthened or 
attenuated, depending on its association with 
positive or negative consequences (Feldman, 1 997). 
The strengthening of responses occurs by positive 
reinforcement, such as food, pleasurable activities, 
and attention from others. The attenuation or 
discontinuation of responses occurs by negative 
reinforcement in the form of removal of a 
pleasurable stimulus. Thus, human behavior is 
shaped in a trial and error way through positive and 
negative reinforcement, without any reference to 
inner conflicts or perceptions. What goes on inside 



56 



The Fundamentals of Mental Health and Mental Illness 



the individual is irrelevant, for humans are equated 
with "black boxes." Mental disorders represented 
maladaptive behaviors that were learned. They 
could be unlearned through behavior modification 
(behavior therapy) (Kazdin, 1996; 1997). 

The movement beyond behaviorism was 
spearheaded by Albert Bandura (1969, 1977), the 
originator of social learning theory (also known as 
social cognitive theory). Social learning theory has 
its roots in behaviorism, but it departs in a 
significant way. While acknowledging classical and 
operant conditioning, social learning theory places 
far greater emphasis on a different type of learning, 
particularly observational learning. Observational 
learning occurs through selectively observing the 
behavior of another person, a model. When the 
behavior of the model is rewarded, children are 
more likely to imitate the behavior. For example, a 
child who observes another child receiving candy 
for a particular behavior is more likely to carry out 
similar behaviors. Social learning theory asserts 
that people's cognitions — their views, perceptions, 
and expectations toward their environment — affect 
what they learn. Rather than being passively 
conditioned by the environment, as behaviorism 
proposed, humans take a more active role in 
deciding what to learn as a result of cognitive 
processing. Social learning theory gave rise to 
cognitive-behavioral therapy, a mode of treatment 
described later in this chapter and throughout this 
report. 

The Integrative Science of Mental Illness 
and Health 

Progress in understanding depression and schizo- 
phrenia offers exciting examples of how findings 
from different disciplines of the mental health field 
have many common threads (Andreasen, 1997). 
Despite the differences in terminology and 
methodology, the results from different disciplines 
have converged to paint a vivid picture of the 
nature of the fundamental defects and the regions 
of the brain that underlie these defects. Even in the 
case of depression and schizophrenia, there is much 



to be uncovered about etiology, yet the mental 
health field is seen as poised "to use the power of 
multiple disciplines." The disciplines are urged to 
link together the study of the mind and the brain in 
the search for understanding mental health and 
mental illness (Andreasen, 1997). 

This linkage already has been cemented 
between cognitive psychology, behavioral 
neurology, computer science, and neuroscience. 
These disciplines have knit together the field of 
"cognitive neuroscience" (Kosslyn & Shin, 1992). 
This new and joint discipline has carved out its 
own professional society, journals (Waldrop, 
1993), and textbooks (Gazzaniga et al., 1998). 
There is movement toward integration of other 
disciplines within the field. To promote linkages 
between psychiatry and the neurosciences, neuro- 
scientist Eric R. Kandel has furnished a novel 
approach. His essay, "A New Intellectual Frame- 
work for Psychiatry," supplies a set of biological 
principles to forge a rapprochement — conceptual as 
well as practical — between the two disciplines 
(Kandel, 1998). Integrated approaches are seen as 
vital to tackle the monumental complexity of 
mental function. 

Overview of Development, 
Temperament, and Risk Factors 

How we come to be the way we are is through the 
process of development. Generally defined as the 
lifelong process of growth, maturation, and change, 
development is the product of the elaborate 
interplay of biological, psychological, and social 
influences. By studying development, researchers 
hope to uncover the origins of both mental health 
and mental illness. 

This section elaborates and extends concepts 
introduced above regarding the fundamental 
workings of the brain at different developmental 
stages. It then proceeds to explain several seminal 
theories of development pioneered by Jean Piaget, 
Erik Erikson, and John Bowlby. Their theories 
cover cognitive development, personality 
development, and social development, respectively. 



57 



Mental Health: A Report of the Surgeon General 



although there is some overlap. Their major works, 
published in the 1950s and 1960s, were pivotal for 
the psychological and social sciences, galvanizing 
a huge body of theoretical and empirical research. 
However, with the advancements of science and the 
diversity of the population, these models may not 
apply to all groups without some adaptation for 
cultural context. The section concludes with a 
reminder that the brain is the "great synthesizer" of 
the many biological, psychological, and sociocul- 
tural phenomena that make us who we are. 

Physical Development 

Physical development of the nervous system 
provides the architecture for mental function 
(cognition, mood, and intentional behavior). As can 
be inferred from the discussion of brain complexity 
in the introductory section, nervous system 
development is arguably one of the most monu- 
mentally complicated developmental achievements. 
One hundred billion neurons must form elaborate 
and precise arrays of interconnections. Neurons 
begin the developmental process as 
undifferentiated cells, cells so seemingly 
anonymous that they are almost indistinguishable 
from other cells in an embryo. On the basis of 
genetic and epigenetic'" influences, the cells must 
first specialize, or differentiate, into neurons, 
migrate to their final position, and then send their 
growing axons (the branch of a neuron that 
transmits impulses) to project over long distances 
in order to form synapses with distant target cells 
(Kandel et al., 1995). 

Most neurobiologists are astounded at the level 
of precision that neurons achieve in their 
interconnections. The process of nervous system 
development has been studied at increasingly 
complex levels — molecular, cellular, tissue, and 
behavioral levels. Yet, while researchers have 
charted many of the behavioral milestones of 
development because they are so amenable to 



observation and analysis, far less is known about 
molecular, cellular, and tissue interactions that 
underlie them. 

Four overarching findings or organizing 
principles have been gleaned from decades of 
neuroscience research. The first finding is that the 
formation of connections between neurons and their 
target cells depends on axons growing along 
anatomical pathways that are studded with 
signaling molecules, much like landing lights 
illuminate the runway for a descending plane. The 
second finding is that an axon's reaching the 
vicinity of, and locating, its correct target cell 
depends on diffusable chemical signals being 
transmitted from the target cell. The third finding 
is that if an axon does not reach its correct target, 
it is likely to die. This phenomenon, known as cell 
death, or apoptosis, is so common that it affects up 
to half of all developing neurons. The brain 
overproduces the number of cells it needs, from 
which it pares down to only the correct connections 
(Kandel et al., 1995). Finally, neuron activity is 
essential to strengthening the connections that are 
formed. In other words, stimulation from the 
environment — which is translated into neuron 
activity — is vital for the forging of normal neural 
development (Shatz, 1993; Kandel, 1995). This is 
a fundamental principle that is revisited later in this 
section. This principle helps to explain why, for 
example, babies who are deprived of a stimulating 
environment during their first year sometimes 
suffer irreparable developmental effects. 

Behavior at birth consists of a repertoire of 
simple reflexes, that is, inborn neurological 
reactions that are involuntary in nature. Two 
examples are the sucking reflex and the rooting 
reflex," both of which are designed to ensure food 
intake. Over time, the infant displays an expanded 
repertoire of fine and gross motor skills (e.g., 
crawling, walking) that begin to unfold in the first 
few months and year of life. These include the 



'" Epigenetic influences are those that arise from outside the genes 
and lead to emergent, as opposed to predetermined, properties. 



" Newborns turn their head towards things — typically the 
breast — that touch their cheek. 



58 



The Fundamentals of Mental Health and Mental Illness 



cherished ability to smile, which helps to solidify 
a social bond with parents and caregivers. What 
begins as a child's biological survival need for 
food — evidenced by such behaviors as rooting and 
sucking — can turn into a social, interpersonal 
experience with the caregiver, as in the smile of an 
infant at the sight of a nurturing parent. These 
burgeoning motor capabilities are the forerunners 
of more complex behavioral and mental functions, 
but the actual relationships between early and later 
abilities, and their molecular and cellular basis, are 
understood only in the most rudimentary terms. 

Theories of Psychological Development 

Theories of human development are grounded in 
the developmental perspective. The developmental 
perspective takes into account the biological, 
social, and psychological environment; their 
interaction; and their combined effect upon the 
individual throughout the life span. 
Developmentalist L. Breger (1974) proposes that 
the developmental perspective incorporates three 
key precepts: 

• Behavioral maturation proceeds from the 
simple to the complex; 

• Future behaviors, whether temporally near or 
distant, are a product of their antecedents (prior 
responses to the developmental environment); 
and 

• The human response to a particular event or 
experience often depends on the developmental 
stage at which the experience occurs. 

Each of these precepts is thought to apply to 
neurobiological development, as well as behav- 
ioral/psychosocial development. Moreover, each 
has implications for whether an individual 
experiences either healthful or unhealthful 
development that may lead to a mental disorder. 

The three precepts are at the heart of each of 
the three major mainstream theories of 
developmental psychology that have guided 
research and increased our understanding of both 
normal and abnormal human development across 
the life span. The following paragraphs offer brief 



sketches of the developmental theories of Jean 
Piaget, Erik Erikson, and John Bowlby; again, these 
sketches are provided to afford the reader an 
historical perspective of research on psychological 
development. 

Piaget: Cognitive Developmental Theory 

Jean Piaget formulated one of the most influential 
theories of cognitive development (Inhelder & 
Piaget, 1958). Its focus was on cognitive 
(intellectual) development, that is, the processes by 
which children come to know and understand the 
world. Other aspects of human growth, both 
physical and emotional, are beyond the scope of his 
theory. Piaget posited that each step of cognitive 
development proceeds from the previous step in a 
fixed pattern, beginning at birth and ending in the 
teen years. 

Piaget had a seminal influence on the discipline 
of cognitive psychology. Although empirical 
research has called into question some of the 
specifics of his theories, the broad outlines remain 
widely accepted. 

Erik Erikson: Psychoanalytic Developmental 
Theory 

The psychoanalytic theory of development is best 
exemplified in the work of Erik Erikson, a 
psychoanalyst who expanded upon Freud' s original 
theories of psychosexual development. One of 
Erikson' s pioneering contributions was that 
development unfolded throughout the life span, a 
view that has become widely embraced. 

Freud postulated that development proceeded 
through a series of stages in which children seek 
pleasure or gratification from a particular body part 
(i.e., the oral, anal, and phallic stage). In contrast, 
Erikson' s theories of child development focus on 
the interrelationship between a developing child's 
internal psychosexual development and his or her 
more external emotional development, emphasizing 
the interpersonal relationships that arise between 
the child and parents (Erikson, 1950). 



59 



Mental Health: A Report of the Surgeon General 



Erikson conceived of the life course, from birth 
to old age, as a series of eight epigenetic stages 
that, as other developmental theories, proceed in a 
stepwise fashion, the next dependent upon how 
well the previous has been mastered: trust versus 
mistrust; autonomy versus shame and doubt; 
initiative versus guilt; industry versus inferiority; 
identity versus role diffusion; intimacy versus 
isolation; generativity versus stagnation; ego 
integrity versus despair. 

Erikson portrayed each stage as a crisis or 
conflict that needed resolution, either at the time or 
at a subsequent stage. Each successive stage 
presents its own challenges but, at the same time, 
offers the opportunity for correction of unresolved 
challenges of previous stages. At each stage the 
tension was between the psychosocial and 
psychosexual — the outward-looking versus inward- 
looking perspectives. Psychopathology, in the form 
of a mental disorder, would arise if a stage was 
ultimately not mastered successfully. 

Over the years, Erikson' s theory has had great 
heuristic value to guide theorists and practitioners 
in organizing their approach to mental health and 
mental illness. However, his theory does not readily 
lend itself to empirical scrutiny. His theory also has 
been criticized as reflecting the concerns of male 
European culture (where Erikson was born and 
trained before moving to the United States) rather 
than those of women and other cultures. The need 
for cultural sensitivity and competence is discussed 
later in this chapter. 

John Bowlby: Attachment Theory of 
Development 

Fifty years ago, a new conceptualization of the 
psychoanalytic approach to development came into 
the lexicon of human development theory. John 
Bowlby' sreinterpretation of Freudian development 
is grounded in both Darwinian evolutionary theory 
and animal ethology. The previous work of Konrad 
Lorenz and others, who explored the relationship 
between other animals and their caregivers, 
determined that the bonds of infant care and the 



attachment of young to their caregivers are seminal 
in the drive for survival. Similarly, Bowlby 
theorized that for humans, attachment to a 
caregiver had a biological basis in the need for 
survival (Bowlby, 1951). Moreover, he suggested 
that this attachment drive exists alongside the drive 
for nutrition and the sex drive, yet distinct and 
separate from them. Attachment is seen as the 
anchor that enables the developing child to explore 
the world. 

With the comfort and security of a stable and 
routine attachment to the mother — or other primary 
caregiver — a child is able to organize other 
elements of development in a coherent way. In 
contrast, instability in the caregiving relation- 
ship — whether physical distance, erratic patterns of 
parental behavior, or even physical or emotional 
abuse — may interfere with the sense of trust and 
security, potentially giving rise to anxiety and 
psychological problems later in childhood or even 
decades later in life. 

Nature and Nurture: The Ultimate 
Synthesis 

For over a century, an intense debate among 
developmentalists and other scientists has pitted 
nature (genetic inheritance) against nurture 
(environment) as the engine of human development 
and behavior. Francis Galton, a 19th-century 
geneticist and cousin of Charles Darwin, declared 
that "there is no escape from the conclusion that 
nature prevails enormously over nurture" (cited in 
Plomin, 1996). As the debate raged, either nature or 
nurture gained ascendancy. During the 1940s and 
1950s, for example, behaviorism held sway over 
American psychology with its argument that 
nurture was preeminent. 

The pendulum now is coming to rest with the 
recognition that behavior is the product of both 
nature and nurture (Plomin, 1996). Each 
contributes to the development of mental health and 
mental illness. Nature and nurture are not 
necessarily independent forces but can interact with 



60 



The Fundamentals of Mental Health and Mental Illness 



one another: nature can influence nurture, and 
nurture can influence nature (Plomin, 1996). 

Studies comparing identical and fraternal twins 
have shed light on the contributions of nature and 
nurture. These studies show that for many 
behavioral traits, as well as mental disorders, there 
is a noticeable heritable component (see earlier 
discussion of heritability). Yet even with the most 
highly heritable traits or conditions, identical twins 
who share the same genetic endowment display 
marked differences. Identical twins, for example, 
are concordant for schizophrenia in 46 percent of 
pairs (NIMH, 1998), meaning that more than 50 
percent of pairs are not concordant. Something yet 
unknown about the environment protects against 
the development of schizophrenia in genetically 
identical individuals (Plomin, 1996). 

How do nature and nurture interact? This 
question cannot be directly answered by twin 
studies. Animal models have proven to be fertile 
ground for study of the mechanisms — at the 
molecular and cellular level — by which nature and 
nurture interact. As reviewed earlier, research in 
different animal models has established that the 
environment can alter the structure and function of 
the central nervous system (Baily & Kandel, 1993). 
This holds true not only during early development, 
but also into adulthood. Nurture influences nature, 
right down to detectable changes in the brain. 

During development of the nervous system, 
each neuron forms myriad intricate synaptic 
connections with other neurons, the outcome of the 
interaction of genes and the environment described 
above. In this case, the environment is a very 
general term — it denotes the local extracellular 
environment surrounding the growing neuron, as 
well as what we traditionally think of as the 
environment (sensory environment, psychosocial 
environment, diet, etc.). When a neuron forms a 
synapse with its target cell, the pattern of activity, 
usually furnished by external environmental 
stimulation, strengthens or weakens the developing 
synapse. Only strengthened synaptic connections 
survive early development to form enduring 



connections, while weakened synaptic connections 
are eliminated (Shatz, 1993; Kandel et al., 1995). 
For example, kittens deprived of visual experience 
early in life sustain permanent disruption to 
synapses in parts of their visual cortex (Hubel & 
Wiesel, 1970). 

Later in the course of development, established 
patterns of connections still can be altered by the 
environment — through learning. Studies in a 
variety of animal models have found that certain 
forms of learning lead to changes in the structure 
and function of neurons. With long-term 
memory — the long-term storage of learned 
information — these changes take the form of an 
enhanced number of synaptic connections and 
increased gene expression (Kandel et al., 1995). 
Increased gene expression appears to be for 
synthesis of new proteins needed for the structural 
changes occurring at the synapse (Bailey & Kandel, 
1993). 

Researchers continue to probe for changes in 
the brain associated with mental disorders. They 
have found, for instance, that repeated stress from 
the environment affects the hippocampus, an area 
of the brain located deep within the cerebral 
hemispheres. Research in animals has shown that 
repeated stress triggers atrophy of dendrites of 
certain types of neurons in a segment of the 
hippocampus (Sapolsky, 1996; McEwen, 1998). 
Similarly, imaging studies in humans suggest that 
stress-related disorders (e.g., post-traumatic stress 
disorder) induce possibly irreversible atrophy of 
the hippocampus (McEwen & Magarinos, 1997). 
Anxiety disorders also alter neuroendocrine 
systems (Sullivan et al., 1998). These are some of 
the tantalizing ways in which nurture influences 
nature. 

The mental health field is far from a complete 
understanding of the biological, psychological, and 
sociocultural bases of development, but develop- 
pment clearly involves interplay among these 
influences. Understanding the process of develop- 
ment requires knowledge, ranging from the most 
fundamental level — that of gene expression and 



61 



Mental Health: A Report of the Surgeon General 



interactions between molecules and cells — all the 
way up to the highest levels of cognition, memory, 
emotion, and language. The challenge requires 
integration of concepts from many different 
disciplines. A fuller understanding of development 
is not only important in its own right, but it is 
expected to pave the way for our ultimate 
understanding of mental health and mental illness 
and how different factors shape their expression at 
different stages of the life span. 

Overview of Prevention 

The field of public health has long recognized the 
imperative of prevention to contain a major health 
problem (lOM, 1988). The principles of pre- 
vention were first applied to infectious diseases in 
the form of mass vaccination, water safety, and 
other forms of public hygiene. As successes 
amassed, prevention came to be applied to other 
areas of health, including chronic diseases (lOM, 
1994a). A landmark report published by the 
Institute of Medicine in 1994 extended the concept 
of prevention to mental disorders (lOM, 1994a). 
Reducing Risks for Mental Disorders evaluated the 
body of research on the prevention of mental 
disorders, offered new definitions of prevention, 
and provided recommendations on Federal policies 
and programs, among other goals. 

Preventing an illness from occurring is 
inherently better than having to treat the illness 
after its onset. In many areas of health, increased 
understanding of etiology and the role of risk and 
protective factors in the onset of health problems 
has propelled prevention. In the mental health field, 
however, progress has been slow because of two 
fundamental and interrelated problems: for most 
major mental disorders, there is insufficient 
understanding about etiology and/or there is an 
inability to alter the known etiology of a particular 
disorder. While these have stymied the develop- 
ment of prevention interventions, some successful 
strategies have emerged in the absence of a full 
understanding of etiology. 



Rigorous scientific trials have documented 
successful prevention programs in such areas as 
dysthymia and major depressive disorder (Munoz et 
al., 1987; Clarke et al., 1995), conduct problems 
(Berrento-Clement et al., 1984), and risky 
behaviors leading to HIV infection (Kalichman et 
al., in press) and low birthweight babies (Olds et 
al., 1986). Much progress also has been made to 
prevent the occurrence of lead poisoning, which, if 
unchecked, can lead to serious and persistent 
cognitive deficits in children (Centers for Disease 
Control and Prevention, 1991; Pirkle et al., 1994). 
Lastly, historical milestones in prevention of 
mental illness led to the successful eradication of 
neurosyphilis, pellagra, and measles encephalo- 
myelitis (measles invasion of the brain) in the 
developed world. 

Definitions of Prevention 

The term "prevention" has different meanings to 
different people. It also has different meanings to 
different fields of health. The classic definitions 
used in public health distinguish between primary 
prevention, secondary prevention, and tertiary 
prevention (Commission on Chronic Illness, 1957). 
Primary prevention is the prevention of a disease 
before it occurs; secondary prevention is the 
prevention of recurrences or exacerbations of a 
disease that already has been diagnosed; and 
tertiary prevention is the reduction in the amount of 
disability caused by a disease to achieve the highest 
level of function. 

The Institute of Medicine report on prevention 
identified problems in applying these definitions to 
the mental health field (lOM, 1994a). The problems 
stemmed mostly from the difficulty of diagnosing 
mental disorders and from shifts in the definitions 
of mental disorders over time (see Diagnosis of 
Mental Illness). Consequently, the Institute of 
Medicine redefined prevention for the mental 
health field in terms of three core activities: 
prevention, treatment, and maintenance (lOM, 
1994a). Prevention, according to the lOM report, is 
similar to the classic concept of primary prevention 



62 



The Fundamentals of Mental Health and Mental Illness 



from public health; it refers to interventions to 
ward off the initial onset of a mental disorder. 
Treatment refers to the identification of individuals 
with mental disorders and the standard treatment 
for those disorders, which includes interventions to 
reduce the likelihood of future co-occurring 
disorders. And maintenance refers to interventions 
that are oriented to reduce relapse and recurrence 
and to provide rehabilitation. (Maintenance 
incorporates what the public health field 
traditionally defines as some forms of secondary 
and all forms of tertiary prevention.) 

The Institute of Medicine's new definitions of 
prevention have been very important in 
conceptualizing the nature of prevention activities 
for mental disorders; however, the terms have not 
yet been universally adopted by mental health 
researchers. As a result, this report strives to use 
the terms employed by the researchers themselves. 
To avoid confusion, the report furnishes the 
relevant definition along with study descriptions. 

When the term "prevention" is used in this 
report without a qualifying term, it refers to the 
prevention of the initial onset of a mental disorder 
or emotional or behavioral problem, including 
prevention of comorbidity. First onset corresponds 
to the initial point in time when an individual's 
mental health problems meet the full criteria for a 
diagnosis of a mental disorder. 

Risk Factors and Protective Factors 

The concepts of risk and protective factors, risk 
reduction, and enhancement of protective factors 
(also sometimes referred to as fostering resilience) 
are central to most empirically based prevention 
programs. Risk factors are those characteristics, 
variables, or hazards that, if present for a given 
individual, make it more likely that this individual, 
rather than someone selected at random from the 
general population, will develop a disorder 
(Garmezy, 1983; Werner & Smith, 1992; lOM, 
1994a). To qualify as a risk factor the variable must 
antedate the onset of the disorder. Yet risk factors 
are not static. They can change in relation to a 



developmental phase or a new stressor in one's life, 
and they can reside within the individual, family, 
community, or institutions. Some risks such as 
gender and family history are fixed; that is, they are 
not malleable to change. Other risk factors such as 
lack of social support, inability to read, and 
exposure to bullying can be altered by strategic and 
potent interventions (Coie & Krehbiel, 1984; 
Silverman, 1988; Olweus, 1991; Kellam & Rebok, 
1992). Current research is focusing on the interplay 
between biological risk factors and psychosocial 
risk factors and how they can be modified. As 
explained earlier, even with a highly heritable 
condition such as schizophrenia, concordance 
studies showthatinoverhalf of identical twins, the 
second twin does not have schizophrenia. This 
suggests the possibility of modifying the 
environment to eventually prevent the biological 
risk factor (i.e., the unidentified genes that 
contribute to schizophrenia) from being expressed. 
Prevention not only focuses on the risks 
associated with a particular illness or problem but 
also on protective factors. Protective factors 
improve a person' s response to some environmental 
hazard resulting in an adaptive outcome (Rutter, 
1979). Such factors, which can reside with the 
individual or within the family or community, do 
not necessarily foster normal development in the 
absence of risk factors, but they may make an 
appreciable difference on the influence exerted by 
risk factors (lOM, 1994a). There is much to be 
learned in the mental health field about the role of 
protective factors across the life span and within 
families as well as individuals. The potential for 
altering these factors in intervention studies is 
enormous. The construct of "resilience" is related 
to the concept of protective factors, but it focuses 
more on the ability of a single individual to 
withstand chronic stress or recover from traumatic 
life events. There are many different perceptions of 
what constitutes resilience or "competence," 
another related term. Despite the increasing 
popularity of these ideas, "virtually no intervention 



63 



Mental Health: A Report of the Surgeon General 



studies have been conducted that test the outcomes 
of resilience variables" (Grover, 1998). 

Preventive researchers use risk status to 
identify populations for intervention, and then they 
target risk factors that are thought to be causal and 
malleable and target protective factors that are to 
be enhanced. If the interventions are successful, the 
amount of risk decreases, protective factors 
increase, and the likelihood of onset of the 
potential problem also decreases. The risks for 
onset of a disorder are likely to be somewhat 
different from the risks involved in relapse of a 
previously diagnosed condition. This is an 
important distinction because at-risk terminology is 
used throughout the mental health intervention 
spectrum. The optimal treatment protocol for an 
individual with a serious mental condition aims to 
reduce the length of time the disorder exists, halt a 
progression of severity, and halt the recurrence of 
the original disorder, or if not possible, to increase 
the length of time between episodes (lOM, 1994a). 
To do this requires an assessment of the 
individual's specific risks for recurrence. 

Many mental health problems, especially in 
childhood, share some of the same risk factors for 
initial onset, so targeting those factors can result in 
positive outcomes in multiple areas. Risk factors 
that are common to many disorders include 
individual factors such as neurophysiological 
deficits, difficult temperament, chronic physical 
illness, and below-average intelligence; family 
factors such as severe marital discord, social 
disadvantage, overcrowding or large family size, 
paternal criminality, maternal mental disorder, and 
admission into foster care; and community factors 
such as living in an area with a high rate of 
disorganization and inadequate schools (lOM, 
1994a). Also, some individual risk factors can lead 
to a state of vulnerability in which other risk 
factors may have more effect. For example, low 
birthweight is a general risk factor for multiple 
physical and mental outcomes; however, when it is 
combined with a high-risk social environment, it 
more consistently has poorer outcomes (McGauhey 



et al., 1991). The accumulation of risk factors 
usually increases the likelihood of onset of 
disorder, but the presence of protective factors can 
attenuate this to varying degrees. 

The concept of accumulation of risks in 
pathways that accentuate other risks has led 
prevention researchers to the concept of "breaking 
the chain at its weakest links" (Robins, 1970; lOM, 
1994a). In other words, some of the risks, even 
though they contribute significantly to onset, may 
be less malleable than others to intervention. The 
preventive strategy is to change the risks that are 
most easily and quickly amenable to intervention. 
For example, it may be easier to prevent a child 
from being disruptive and isolated from peers by 
altering his or her classroom environment and 
increasing academic achievement than it is to 
change the home environment where there is severe 
marital discord and substance abuse. 

Because mental health is so intrinsically 
related to all other aspects of health, it is 
imperative when providing preventive interventions 
to consider the interactions of risk and protective 
factors, etiological links across domains, and 
multiple outcomes. For example, chronic illness, 
unemployment, substance abuse, and being the 
victim of violence can be risk factors or mediating 
variables for the onset of mental health problems 
(Kaplan et al., 1987). Yet some of the same factors 
also can be related to the consequences of mental 
health problems (e.g., depression may lead to 
substance abuse, which in turn may lead to lung or 
liver cancer). 

Overview of Treatment 

Introduction to Range of Treatments 

Mental disorders are treatable, contrary to what 
many think. ^^ An armamentarium of efficacious 
treatments is available to ameliorate symptoms. In 



'- About 40 percent of those surveyed thought that they "didn't think 
anyone could help" as a reason for not seeking mental health 
treatment (Sussman et al., 1987). 



64 



The Fundamentals of Mental Health and Mental Illness 



fact, for most mental disorders, there is generally 
not just one but a range of treatments of proven 
efficacy. Most treatments fall under two general 
categories, psychosocial and pharmacological.'^ 
Moreover, the combination of the two — known as 
multimodal therapy — can sometimes be even more 
effective than each individually (see Chapter 3). 

The evidence for treatment being more effective 
than placebo is overwhelming, as documented in 
the main chapters of this report (Chapters 3 through 
5). The degree of effectiveness tends to vary, 
depending on the disorder and the target population 
(e.g., older adults with depression). What is 
optimal for one disorder and/or age group may not 
be optimal for another. Further, treatments 
generally need to be tailored to the client and to 
client preferences. 

The inescapable point is that studies 
demonstrate conclusively that treatment is more 
effective than placebo. Placebo (an inactive form of 
treatment) in both pharmacological and psycho- 
therapy studies has a powerful effect in its own 
right, as this section later explains. Placebo is more 
effective than no treatment. Therefore, to capitalize 
on the placebo response, people are encouraged to 
seek treatment, even if the treatment is not as 
optimal as that described in this report. 

If treatment is so effective, then why are so few 
people receiving it? Studies reveal that less than 
one-third of adults with a diagnosable mental 
disorder, and even a smaller proportion of children, 
receive any mental health services in a given year. 
This section of the chapter strives to explain why 
by examining the types of barriers that prevent 
people from seeking help. But the chapter first 
covers some general points about psychological and 
pharmacological therapies. It also discusses why 
therapies that work so well in research settings do 
not work as well in practice. 



" Other treatments are electroconvulsive therapy (Chapters 4 and 5) and 
some types of surgery. 



Psychotherapy 

Psychotherapy is a learning process in which 
mental health professionals seek to help individuals 
who have mental disorders and mental health 
problems. It is a process that is accomplished 
largely by the exchange of verbal communication, 
hence it often is referred to as "talk therapy." 
Many of the theories undergirding each orientation 
to psychotherapy were summarized earlier in this 
chapter. 

Participants in psychotherapy can vary in age 
from the very young to the very old, and problems 
can vary from mental health problems to disabling 
and catastrophic mental disorders. Although people 
often are seen individually, psychotherapy also can 
be done with couples, families, and groups. In each 
case, participants present their problems and then 
work with the psychotherapist to develop a more 
effective means of understanding and handling 
their problems. This report focuses on individual 
psychotherapy and also mentions couples therapy 
and various forms of family interventions, 
particularly psycho-educational approaches. 
Although not discussed in the report, group 
psychotherapy is effective for selected individuals 
with some mood disorders, anxiety disorders, 
schizophrenia, personality disorders, and for mental 
health problems seen in somatic illness (Yalom, 
1995; Kanas, in press). 

Estimates of the number of orientations to 
psychotherapy vary from a very small number to 
well over 400. The larger estimate generally refers 
to all the variations of the three major orientations, 
that is, psychodynamic, behavioral, and humanistic. 
Each orientation falls under the more general 
conceptual category of either action or reflection. 

Psychodynamic orientations are the oldest. 
They place a premium on self-understanding, with 
the implicit (or sometimes explicit) assumption that 
increased self-understanding will produce salutary 
changes in the participant. Behavioral orientations 
are geared toward action, with a clear attempt to 
mobilize the resources of the patient in the 
direction of change, whether or not there is any 



65 



Mental Health: A Report of the Surgeon General 



understanding of the etiology of the problem. 
Humanistic orientations aim toward increased self- 
understanding, often in the direction of personal 
growth, but use treatment techniques that often are 
much more active than are likely to be employed by 
the psychodynamic clinician. 

While the following paragraphs focus on 
psychodynamic, behavioral, and humanistic 
orientations, they also discuss interpersonal therapy 
and cognitive-behavioral therapy as outgrowths of 
psychodynamic and behavioral therapy, respect- 
ively. Psychodynamic, interpersonal, and cognitive- 
behavioral therapy are most commonly the focus of 
treatment research reported throughout this report. 

Psychodynamic Therapy 

The first major approach to psychotherapy was 
developed by Sigmund Freud and is called 
psychoanalysis (Horowitz, 1988). Since its origin 
more than a century ago, psychoanalysis has 
undergone many changes. Today, Freudian (or 
classical) psychoanalysis is still practiced, but 
other variations have been developed — ego 
psychology, object relations theory, interpersonal 
psychology, and self-psychology, each of which 
can be grouped under the general term 
"psychodynamic" (Horowitz, 1988). The 
psychodynamic therapies, even though they differ 
somewhat in theory and approach, all have some 
concepts in common. With each, the role of the past 
in shaping the present is emphasized, so it is 
important, in understanding behavior, to understand 
its origins and how people come to act and feel as 
they do. A second critical concept common to all 
psychodynamic approaches is the belief in the 
unconscious, so that there is much that influences 
our behavior of which we are not aware. This 
makes the process of understanding more difficult, 
as we often act for reasons that we cannot state, and 
these reasons often are linked to previous 
experiences. Thus, an important part of 
psychodynamic psychotherapy is to make the 
unconscious conscious or to help the patient 



understand the origin of actions that are troubling 
so that they can be corrected. 

For some psychodynamic approaches, such as 
the classical Freudian approach, the focus is on the 
individual and the experiences the person had in the 
early years that give shape to current behavior, 
even beyond the awareness of the patient. For 
other, more contemporary approaches, such as 
interpersonal therapy, the focus is on the 
relationship between the person and others. First 
developed as a time-limited treatment for midlife 
depression, interpersonal therapy focuses on grief, 
role disputes, role transitions, and interpersonal 
deficits (Klerman et al., 1984). The goal of 
interpersonal therapy is to improve current 
interpersonal skills. The therapist takes an active 
role in teaching patients to evaluate their 
interactions with others and to become aware of 
self-isolation and interpersonal difficulties. The 
therapist also offers advice and helps the patient to 
make decisions. 

Behavior Therapy 

A second major approach to psychotherapy is 
known as behavior modification or behavior 
therapy (Kazdin, 1996, 1997). It focuses on current 
behavior rather than on early patterns of the 
patient. In its earlier form, behavior therapy dealt 
exclusively with what people did rather than what 
they thought or felt. The general principles of 
learning were applied to the learning of maladap- 
tive as well as adaptive behaviors. Thus, if a person 
could be conditioned to act in a functional way, 
there was no reason why the same principles of 
conditioning could not be employed to help the 
person unlearn dysfunctional behavior and learn to 
replace it with more functional behavior. The role 
of the environment was very important for behavior 
therapists, because it provided the positive and 
negative reinforcements that sustained or 
eliminated various behaviors. Therefore, ways of 
shaping that environment to make it more 
responsive to the needs of the individual were 
important in behavior therapy. 



66 



The Fundamentals of Mental Health and Mental Illness 



More recently, there has been a significant 
addition to the interests and activities of behavior 
therapists. Although behavior continued to be 
important in relation to reinforcements, cog- 
nitions — what the person thought about, perceived, 
or interpreted what was transpiring — were also 
seen as important. This combined emphasis led to 
a therapeutic variant known as cognitive- 
behavioral therapy, an approach that incorporates 
cognition with behavior in understanding and 
altering the problems that patients present (Kazdin, 
1996). 

Cognitive-behavioral therapy draws on 
behaviorism as well as cognitive psychology, a 
field devoted to the scientific study of mental 
processes, such as perceiving, remembering, 
reasoning, decisionmaking, and problem solving. 
The use of cognition in cognitive-behavioral 
therapy varies from attending to the role of the 
environment in providing a model for behavior, to 
the close study of irrational beliefs, to the 
importance of individual thought processes in 
constructing a vision of the surrounding world. In 
each case, it is critical to study what the individual 
in therapy thinks and does and less important to 
understand the past events that led to that pattern of 
thinking and doing. Cognitive-behavioral therapy 
strives to alter faulty cognitions and replace them 
with thoughts and self-statements that promote 
adaptive behavior (Beck et al., 1979). For instance, 
cognitive-behavioral therapy tries to replace self- 
defeatist expectations ("I can't do anything right") 
with positive expectations ("I can do this right"). 
Cognitive-behavioral therapy has gained such 
ascendancy as a means of integrating cognitive and 
behavioral views of human functioning that the 
field is more frequently referred to as cognitive- 
behavioral therapy rather than behavior therapy 
(Kazdin, 1996). 

Humanistic Therapy 

The third wave of psychotherapy is referred to 
variously as humanistic (Rogers, 1961), existential 
(Yalom, 1980), experiential, or Gestalt therapy. It 



owes its origins as a treatment to the client- 
centered therapy that was originated by Carl 
Rogers, and the theory can be traced to 
philosophical roots beginning with the 1 9th century 
philosopher, Soren Kierkegaard. The central focus 
of humanistic therapy is the immediate experience 
of the client. The emphasis is on the present and the 
potential for future development rather than on the 
past, and on immediate feelings rather than on 
thoughts or behaviors. It is rooted in the everyday 
subjective experience of the person seeking 
assistance and is much less concerned with mental 
illness than it is with human growth. 

One critical aspect of humanistic treatment is 
the relationship that is forged between the 
therapist, who in some ways serves as a guide in an 
exploration of self-discovery, and the client, who is 
seeking greater knowledge of the self and an 
expansion of inherent human potential. The focus 
on the self and the search for self-awareness is akin 
to psychodynamic psychotherapy, while the 
emphasis on the present is more similar to behavior 
therapy. 

Although it is possible to describe distinctive 
orientations to psychotherapy, as has been done 
above, most psychotherapists describe themselves 
as eclectic in their practice, rather than as adherents 
to any single approach to treatment. As a result, 
there is a growing development referred to as 
"psychotherapy integration" (Wolfe & Goldfried, 
1988). It strives to capture what is best about each 
of the individual approaches. Psychotherapy 
integration includes various attempts to look 
beyond the confines of any single orientation but 
rather to see what can be learned from other 
perspectives. It is characterized by an openness to 
various ways of integrating diverse theories and 
techniques. Psychotherapy also should be modified 
to be culturally sensitive to the needs of racial and 
ethnic minorities (Acosta et al., 1982; Sue et al., 
1994; Lopez, in press). 

The scientific evidence on efficacy presented in 
this report, however, is focused primarily on 
specific, standardized forms of psychotherapy. 



67 



Mental Health: A Report of the Surgeon General 



Pharmacological Therapies 

The past decade has seen an outpouring of new 
drugs introduced for the treatment of mental 
disorders (Nemeroff, 1998). New medications for 
the treatment of depression and schizophrenia are 
among the achievements stoked by research 
advances in both neuroscience and molecular 
biology. Through the process known as rational 
drug design, researchers have become increasingly 
sophisticated at designing drugs by manipulating 
their chemical structures. Their goal is to create 
more effective therapeutic agents, with fewer side 
effects, exquisitely targeted to correct the 
biochemical alterations that accompany mental 
disorders. 

The process was not always so rational. Many 
of the older pharmacotherapies (drug treatments) 
that had been introduced by 1960 had been 
discovered largely by accident. Researchers 
studying drugs for completely different purposes 
serendipitously found them to be useful for treating 
mental disorders (Barondes, 1993). Thanks to their 
willingness to follow up on unexpected leads, drugs 
such as chlorpromazine (for psychosis), lithium 
(for bipolar disorder), and imipramine (for 
depression) became available. The advent of 
chlorpromazine in 1952 and other neuroleptic drugs 
was so revolutionary that it was one of the major 
historical forces behind the deinstitutionalization 
movement that is discussed later in this chapter. 

The past generation of pharmacotherapies, once 
shown to be safe and effective, was introduced to 
the market generally before their mechanism of 
action was understood. Years of research after their 
introduction revealed how many of them work 
therapeutically. Knowledge about their actions has 
had two cardinal consequences: it helped probe the 
etiology of mental disorders, and it ushered in the 
next generation of pharmacotherapies that are more 
selective in their mechanism of action. 

Mechanisms of Action 

The mechanism of action refers to how a 
pharmacotherapy interacts with its target in the 



body to produce therapeutic effects. Pharma- 
cotherapies that act in similar ways are grouped 
together into broad categories (e.g., stimulants, 
antidepressants). Within each category are several 
chemical classes. The individual pharmacotherapies 
within a chemical class share similar chemical 
structures. Table 2-9 presents several common 
categories and classes, along with their indication, 
that is, their clinical use. 

Many pharmacotherapies for mental disorders 
have as their initial action the alteration — either 
increase or decrease — in the amount of a 
neurotransmitter. Neurotransmitter levels can be 
altered by pharmacotherapies in myriad ways: 
pharmacotherapies can mimic the action of the 
neurotransmitter in cell-to-cell signaling; they can 
block the action of the neurotransmitter; or they 
can alter its synthesis, breakdown (degradation), 
release, or reuptake, among other possibilities 
(Cooper et al., 1996). 

Neurotransmitters generally are concentrated in 
separate brain regions and circuits. Within the cells 
that form a circuit, each neurotransmitter has its 
own biochemical pathway for synthesis, 
degradation, and reuptake, as well as its own 
specialized molecules known as receptors. At the 
time of neurotransmission, when a traveling signal 
reaches the tip (terminal) of the presynaptic cell, 
the neurotransmitter is released from the cell into 
the synaptic cleft. It migrates across the synaptic 
cleft in less than a millisecond and then binds to 
receptors situated on the membrane of the 
postsynaptic cell. The neurotransmitter' s binding to 
the receptor alters the shape of the receptor in such 
a way that the neurotransmitter can either excite the 
postsynaptic cell, and thereby transmit the signal to 
this next cell, or inhibit the receptor, and thereby 
block signal transmission. The neurotransmitter's 
action is terminated either by enzymes that degrade 
it right there, in the synaptic cleft, or by transporter 
proteins that return unused neurotransmitter back to 
the presynaptic neuron for reuse, a "recycling" 
process known as reuptake. The widely prescribed 
class of antidepressants referred to as the selective 



68 



The Fundamentals of Mental Health and Mental Illness 



Table 2-9. Selected types of pharmacotherapies 




Category and Class 


Example(s) of Clinical Use 


Antipsychotics (neuroleptics) 


Schizophrenia, psychosis 


Typical antipsychotics* 




Atypical antipsychotics** 




Antidepressants 


Depression, anxiety 


Selective serotonin 




reuptal<e inhibitors 




Tricyclic and heterocyclic 




antidepressants*** 




Monoamine oxidase inhibitors 




Stimulants 


Attention-deficit/hyperactivity disorder 


Antimanic 


Mania 


Lithium 




Anticonvulsants 




Thyroid supplementation 




Antianxiety (anxiolytics) 


Anxiety 


Benzodiazepines 




Antidepressants 




(3-Adrenergic-blocking drugs 




Cholinesterase inhibitors 


Alzheimer's disease 



* Also known as first-generation antipsychotics, they include these chemical classes: phenothiazines (e.g., chlorpromazine), 

butyrophenones (e.g., haloperidol), and thioxanthenes (Dixon et al., 1995). 
** Also known as second-generation antipsychotics, they include these chemical classes: dibenzoxazepine (e.g., clozapine), 

thienobenzodiazepine (e.g., olanzapine), and benzisoxazole (e.g., risperidone). 
*** Include imipramine and amitriptyline. 

Source: Perry et al., 1997 



serotonin reuptake inhibitors primarily block the 
action of the transporter protein for serotonin, thus 
leaving more serotonin to remain at the synapse 
(Schloss & Williams, 1998). Depression is thought 
to be reflected in decreased serotonin transmission, 
so one rationale for this class of antidepressants is 
to boost the level of serotonin (see Chapter 4). 

Although the effects of reuptake inhibitors on 
neurotransmitter concentrations in the synapse 
occur with the first dose, therapeutic benefit 
typically lags behind by days or weeks. This 
observation has spurred considerable recent 
research on chronic and "downstream" actions of 
psychotropics, particularly antidepressants. For 
example, in animal models the repeated 
administration of nearly all antidepressants is 
associated with a reduction in the number of 



postsynaptic P receptors, so-called down-regulation 
that parallels the time course of clinical effect in 
patients (Schatzberg & Nemeroff, 1998). Some of 
the secondary effects of reuptake inhibitors may be 
mediated by the activation of intraneuronal "second 
messenger" proteins which result from the 
stimulation of postsynaptic receptors (Schatzberg 
& Nemeroff, 1998). 

Receptors for each transmitter come in 
numerous varieties. Not only are there several types 
of receptor for each neurotransmitter, but there may 
be many subtypes. For serotonin, for example, there 
are seven types of receptors, designated 5-HTi-5- 
HTy, and seven receptor subtypes, totaling 14 
separate receptors (Schatzberg & Nemeroff, 1998). 
The pace at which receptors are identified has 



69 



Mental Health: A Report of the Surgeon General 



become so dizzying that these figures are likely to 
be obsolete by the time this paragraph is read. 

A pharmacotherapy typically interacts with a 
receptor in either one of two ways — as an agonist 
or as an antagonist.''* When a pharmacotherapy acts 
as an agonist, it mimics the action of the natural 
neurotransmitter. When a pharmacotherapy acts as 
an antagonist, it inhibits, or blocks, the neuro- 
transmitter's action, often by binding to the 
receptor and preventing the natural transmitter from 
binding there. An antagonist disrupts the action of 
the neurotransmitter. 

The diversity of receptors presents vast 
opportunities for drug development. Through 
rational drug design, pharmacotherapies have 
become increasingly selective in their actions. 
Generally speaking, the more selective the 
pharmacotherapy's action, the more targeted it is to 
one receptor rather than another, the narrower its 
spectrum of action, and the fewer the side effects. 
Conversely, the broader the pharmacotherapy's 
action, the less targeted to a receptor type or 
subtype, the broader the effects, and the broader the 
side effects (Minneman, 1994). However, the 
interaction among neurotransmitter systems in the 
brain renders some of the apparent distinctions 
among medications more apparent than real. Thus, 
despite differential initial actions on neuro- 
transmitters, both serotonin and norepinephrine 
reuptake blockers have similar biochemical effects 
after chronic dosing (Potter et al., 1985). 

Complementary and Alternative Treatment 

Recent interest in the health benefits of a plethora 
of natural products has engendered claims related 
to putative effects on mental health. These have 
ranged from reports of enhanced memory in people 
taking the herb, ginseng, to the use of the St. John's 
wort flowers as an antidepressant (see Chapter 4). 
There are major challenges to evaluating the 
role of complementary and alternative treatments in 



'■' There are certainly exceptions to this general rule. Some 
pharmacotherapies work as partial agonists and partial antagonists 
simultaneously. 



maintaining mental health or treating mental 
disorders. In many cases, preparations are not 
standardized and consist of a variable mixture of 
substances, any of which may be the active 
ingredient(s). Purity, bioavailability, amount and 
timing of doses, and other factors that are 
standardized for traditional pharmaceutical agents 
prior to testing cannot be taken for granted with 
natural products. Current regulations in the United 
States classify most complementary and alternative 
treatments as "food supplements," which are not 
subject to premarketing approval of the Food and 
Drug Administration. 

At present, no conclusions about the role, if 
any, of complementary and alternative treatments 
in mental health or illness can be accepted with 
certainty, as very few claims or studies meet 
acceptable scientific standards. With funding from 
government and private industry, controlled clinical 
trials are under way, including the use of St. John's 
wort (Hypericum perforatum) as a treatment for 
depression, and omega-3 fatty acids (fish oils) as a 
mood stabilizer in bipolar depression. In addition, 
it is important for clinicians and investigators to 
account for any herbs or natural products being 
taken by their patients or research subjects that 
might interact with traditional treatments. 

Issues in Treatment 

The foregoing section has furnished an overview of 
the types and nature of mental health treatment. 
The resounding message, which is echoed 
throughout this report, is that a range of efficacious 
treatments is available. The following material 
deals with four issues surrounding treatment — the 
placebo response, benefits and risks, the gap be- 
tween how well treatments work in clinical trials 
versus in the real world, and the constellation of 
barriers that hinder people from seeking mental 
health treatment. 

Placebo Response 

Recognized since antiquity, the placebo effect 
refers to the powerful role of patients' attitudes and 



70 



The Fundamentals of Mental Health and Mental Illness 



perceptions that help them improve and recover 
from health problems. Hippocrates established the 
therapeutic principle of physicians laying their 
hands in a reassuring manner to draw on the inner 
resources of the patient to fight disease. 
Technically speaking, the placebo effect refers to 
treatment responses in the placebo group, responses 
that cannot be explained on the basis of active 
treatment (Friedman et al., 1996a). A placebo is an 
inactive treatment, either in the form of an inert pill 
for studying a new drug treatment or an inactive 
procedure for studying a psychological therapy. 
The effects of active treatment are often compared 
with a control group that receives a pharm- 
acological or psychological placebo. 

It is not unusual for a placebo effect to be found 
in up to 50 percent of patients in any study of a 
medical treatment (Schatzberg & Nemeroff, 1998). 
For example, about 30 percent of patients typically 
respond to a placebo in a clinical trial of a new 
antidepressant (see Chapter 4). The rate is even 
higher for an antianxiety agent (an anxiolytic) 
(Schweizer & Rickels, 1997). The placebo effect is 
of such import that a placebo group or other control 
group'^ is mandated by the Food and Drug 
Administration in clinical trials of a new 
pharmacotherapy to establish its efficacy prior to 
marketing (Friedman et al., 1996a). If the 
pharmacotherapy is not statistically superior to the 
control, efficacy cannot be established. It is 
somewhat more difficult to fashion an analog of an 
inert pill in the testing of new and experimental 
psychological therapies. Psychological studies can 
employ a "psychological" placebo in the form of a 
treatment known to be ineffectual. Or they can 
employ a comparison group, which receives an 
alternative psychological therapy. Some treatment 
studies employ both a "psychological" placebo, as 
well as a comparison group. '^ 



" When it is unethical to deprive patients of treatment, such as the 
case with AIDS, conventional treatment is given as the control. 

"' The criteria developed by a division of the American 
Psychological Association for establishing treatment efficacy call 
for the experimental treatment to be statistically superior to "pill or 



The basis of the placebo response is not fully 
known, but there are thought to be many possible 
reasons. These reasons, which relate to attributes of 
the disorder or the disease, the patient, and the 
treatment setting, include spontaneous remission, 
personality variables (e.g., social acquiescence), 
patient expectations, attitudes of and compassion 
by clinicians, and receiving treatment in a 
specialized setting (Schweizer & Rickels, 1997). In 
studies of postoperative pain, the placebo response 
is mediated by patients' production of endogenous 
pain-killing substances known as endorphins 
(Levine et al., 1978). 

Benefits and Risks 

Throughout this report, currently accepted 
treatments for mental disorders will be described. 
Except where otherwise indicated, the efficacy of 
these interventions has been documented in 
multiple controlled, clinical trials published in the 
peer-reviewed literature. In some cases, these have 
been supplemented by expert consensus reports or 
practice guidelines. 

Most studies of efficacy of specific treatments 
for mental disorders have been highly structured 
clinical trials, performed on individuals with a 
single disorder, in good physical health. While 
necessary and important, these trials do not always 
generalize easily to the wider population, which 
includes many individuals whose mental disorder is 
accompanied by another mental or somatic disorder 
and/or alcohol or substance abuse, and who may be 
taking other medications. Moreover, children, 
adolescents, and the elderly are excluded from 
many clinical trials,'^ as are those in certain 
settings, such as nursing homes. Newer, more 
generalizable studies are being undertaken to 



psychological placebo or to another treatment" (Chambless et al., 
1998). 

" In March 1998, the NIH issued a policy guideline stating that 
NIH-funded investigators will be expected to include children in 
clinical trials, which normally would involve adults only, when 
there is sound scientific rationale and in the absence of a strong 
justification to the contrary. 



71 



Mental Health: A Report of the Surgeon General 



address these shortcomings of the scientific 
literature (Lebowitz & Rudorfer, 1998). 

Pending the results of these newer studies, it is 
important, for clinical decisionmakers to review the 
current best evidence for the efficacy of treatments. 
People with mental disorders and their health 
providers should consider all possible options and 
carefully weigh the pros and cons of each, as well 
as the possibility of no treatment at all, before 
deciding upon a course of action. Such an informed 
consent process entails the calculation of a 
"benefit-to-risk ratio" for each available treatment 
option. Most medications or somatic treatments 
have side effects, for example, but a likelihood of 
significant clinical benefit often overrides side- 
effects in support of a treatment recommendation. 

Gap Between Efficacy and Effectiveness 

Mental health professionals have long observed 
that treatments work better in the clinical research 
trial setting as opposed to typical clinical practice 
settings. The diminished level of treatment 
effectiveness in real-world settings is so 
perceptible that it even has a name, the "efficacy- 
effectiveness gap." Efficacy is the term for what 
works in the clinical trial setting, and effectiveness 
is the term for what works in typical clinical 
practice settings. The efficacy-effectiveness gap 
applies to both pharmacological therapies and to 
psychotherapies (Munoz et al., 1994; Seligman, 
1995). The gap is not unique to mental health, for 
it is found with somatic disorders too. 

The magnitude of the gap can be surprisingly 
high. With schizophrenia medications, one review 
article found that, in clinical trials, the use of 
traditional antipsychotic medications for 
schizophrenia was associated with an average 
annual relapse rate of about 23 percent, whereas the 
same medications used in clinical practice carried 
a relapse rate of about 50 percent (Dixon et al., 
1995). The magnitude of the gap found in this study 
may not apply to other medications and other 
disorders, much less to psychological therapies. 
Studies of real-world effectiveness are scarce. Yet 



some degree of gap is widely recognized. The 
question is, why? 

Efficacy studies test whether treatment works 
under ideal circumstances. They typically exclude 
patients with other mental or somatic disorders. In 
the past, they typically have examined relatively 
homogeneous populations, usually white males. 
Furthermore, efficacy studies are carried out by 
highly trained specialists following strict protocols 
that require frequent patient monitoring. Finally, 
participation in efficacy studies is often free of 
charge to patients. 

It is not surprising that the reasons commonly 
cited to explain the discrepancy between efficacy 
and effectiveness focus on the practicalities and 
constraints imposed by the real world. In real-world 
settings, patients often are more heterogeneous and 
ethnically diverse, are beset by comorbidity (more 
than one mental or somatic disorder),'^ are often 
less compliant, and are seen more often in general 
medical rather than specialty settings; providers are 
less inclined to adequately monitor and standardize 
treatment; and cost pressures exist on both patients 
and providers, depending on the nature of the 
financing of care (Dixon et al., 1995; Wells & 
Sturm, 1996). This constellation of real-world 
constraints appears to explain the gap. 

Barriers to Seel<ing Help 

Most people with mental disorders do not seek 
treatment, according to figures presented in the 
next section of this chapter and in Chapter 6. This 
general statement applies to adults and older adults 
and to parents and guardians who make treatment 
decisions for children with mental disorders. There 
is a multiplicity of reasons why people fail to seek 
treatment for mental disorders but few detailed 
studies. The barriers to treatment fall under several 
umbrella categories: demographic factors, patient 
attitudes toward a service system that often 



" Having a second disorder increases the possibility of drug 
interactions, which may translate into reduced dosing. Comorbidity 
is discussed throughout this report. 



72 



The Fundamentals of Mental Health and Mental Illness 



neglects the special needs of racial and ethnic 
minorities, financial, and organizational. 

Several demographic factors predispose people 
against seeking treatment. African Americans, 
Hispanics (Sussman et al., 1987; Gallo et al., 
1995), and poor women (Miranda & Green, 1999) 
are less inclined than non-Hispanic 
whites — particularly females — to seek treatment. 
Common patient attitudes that deter people from 
seeking treatment are not having the time, fear of 
being hospitalized, thinking that they could handle 
it alone, thinking that no one could help, and 
stigma (being too embarrassed to discuss the 
problem) (Sussman et al., 1987). Above all, the 
cost of treatment is the most prevalent deterrent to 
seeking care, according to a large study of 
community residents (Sussman et al., 1987). Cost 
is a major determinant of seeking treatment even 
among people with health insurance because of 
inferior coverage of mental health as compared 
with health care in general. Finally, the 
organizational barriers include fragmentation of 
services and lack of availability of services 
(Horwitz, 1987). Members of racial and ethnic 
minority groups often perceive that services offered 
by the existing system do not or will not meet their 
needs, for example, by taking into account their 
cultural or linguistic practices. These particular 
barriers are discussed in greater depth with respect 
to minority groups (later in this chapter) and with 
respect to different ages (Chapters 3 to 5). 

Demographic, attitudinal, financial, and 
organizational barriers operate at various points 
and to various degrees. Seeking treatment is 
conceived of as a complex process that begins with 
an individual or parent recognizing that thinking, 
mood, or behaviors are unusual and severe enough 
to require treatment; interpreting symptoms as a 
"medical" or mental health problem; deciding 
whether or not to seek help and from whom; 
receiving care; and, lastly, evaluating whether 
continuation of treatment is warranted (Sussman et 
al., 1987). 



Overview of Mental Health Services 

Over the past three centuries, the complex 
patchwork of mental health services in the United 
States has become so fragmented that it is referred 
to as the de facto mental health system (Regier et 
al., 1993b). Its shape has been determined by many 
heterogeneous factors rather than by a single 
guiding set of organizing principles. The de facto 
system has been characterized as having distinct 
sectors, financing, duration of care, and settings 
(see Figure 2-4). 

The four sectors of the system are the specialty 
mental health sector, the general medical/primary 
care sector, the human services sector, and the 
voluntary support network sector. Specialty mental 
health services include services provided by 
specialized mental health professionals (e.g., 
psychologists, psychiatric nurses, psychiatrists, and 
psychiatric social workers) and the specialized 
offices, facilities, and agencies in which they work. 
Specialty services were designed expressly for the 
provision of mental health services. The general 
medical/primary care sector consists of health care 
professionals (e.g., family physicians, nurse 
practitioners, internists, pediatricians, etc.) and 
the settings (i.e., offices, clinics, and hospitals) in 
which they work. These settings were designed for 
the full range of health care services, including, but 
not specialized for, the delivery of mental health 
services. The human services sector consists of 
social welfare, criminal justice, educational, 
religious, and charitable services. The voluntary 
support network refers to self-help groups and 
organizations. These are groups devoted to 
education, communication, and support, all of 
which extend beyond formal treatment. 

Financing of the de facto system refers to the 
payer of services. The system is often described as 
being divided into a public (i.e., government) and 
a private sector. The term "public sector" refers 
both to services directly operated by government 
agencies (e.g., state and county mental hospitals) 
and to services financed with government resources 



73 



Mental Health: A Report of the Surgeon General 

Figure 2-4. The mental health service system 



\i 


~ Public ' 








Sectors: 




IM 


Specialty Mental Health 
General Medical/Primary Care 






Human Services 






Voluntary Support Network 






Settings: 

Home 




H 


Community 
Institutions 

Duration of Care: 

Acute Care 
Long-term Care 













(e.g., Medicaid, a Federal-State program for 
financing health care services for people who are 
poor and disabled, and Medicare, a Federal health 
insurance program primarily for older Americans 
and people who retired early due to disability). 
Publicly financed services may be provided by 
private organizations. The term "private sector" 
refers both to services directly operated by private 
agencies and to services financed with private 
resources (e.g., employer-provided insurance). 

The duration of care is divided between 
services for the treatment of acute conditions and 
those devoted to the long-term care of chronic (i.e., 
severe and persistent) conditions, such as 
schizophrenia, bipolar disorder, and Alzheimer's 
disease. The former, provided in psychiatric 
hospitals, psychiatric units in general hospitals, and 
in beds "scattered" in general hospital wards. 



includes brief treatment-oriented services. Long- 
term care includes residential care as well as some 
treatment services. Residential care is often 
referred to as "custodial," when supervised living 
predominates over active treatment. 

The settings for care and treatment include 
institutional, community-based, and home-based. 
The former refers to facilities, particularly public 
mental hospitals and nursing homes, which usually 
are seen by patients and families as large, 
regimented, and impersonal. They often are 
removed from the community by distance and 
frequency of contact with friends and family. In 
contrast, community-based services are close to 
where patients or clients live. Services are typically 
provided by community agencies and organizations. 
Home-based services include informal supports 
provided in an individual's residence. 



74 



The Fundamentals of Mental Health and Mental Illness 



Chapter 6 examines the impact of recent 
changes in financing and organizing services on 
access and quality of care. Many of these issues 
also are addressed in Chapters 3 to 5, where they 
are discussed in the context of care and treatment at 
each stage of the life cycle. The following material 
provides general information on current patterns of 
use and focuses on the historical origins of mental 
health services. 

Overall Patterns of Use 

According to recent national surveys (Regier et al, 
1993b; Kessler et al., 1996), a total of about 15 
percent of the U.S. adult population use mental 
health services in any given year. Eleven percent 
receive their services from either the general 
medical care sector or the specialty mental health 
sector, in roughly equal proportions. In addition, 
about 5 percent receive care from the human 
services sector, and about 3 percent receive care 
from the voluntary support network. (The overlap 
across these latter two sectors accounts for these 
figures totaling more than 15 percent.) 

Slightly more than half of the 15 percent of the 
adult population that use mental health services 
have a diagnosable mental or addictive disorder (8 
percent), while the remaining portion has a mental 
health problem (7 percent). Bearing in mind that 28 
percent of the population have a diagnosable 
mental or substance abuse disorder, only about 
one-third with a diagnosable mental disorder 
receives treatment in 1 year (Figure 2-5). In short, 
this translates to the majority of those with 
a diagnosable mental disorder not receiving 
treatment. 

Similarly, about 21 percent of the child and 
adolescent population use mental health services 
annually. Nine percent receive care from the health 
care sector, almost exclusively from the specialty 
mental health sector. Seventeen percent of the child 
and adolescent population receive care from the 
human services sector, mostly in the school system, 
yet there is much overlap with the health sector 
(again accounting for the sum being more than 21 



percent). The distribution of those who do and do 
not currently meet diagnostic criteria for a mental 
disorder is similar to that for adults (Figure 2-6). 

History of Mental Health Services 

The history of mental health services in the United 
States has been chronicled by historian Gerald N. 
Grob in a series of landmark books from which this 
account is drawn (Grob, 1983, 1991, 1994). The 
origins of the mental health services system 
coincide with the colonial settlement of the United 
States. Individuals with mental illness were cared 
for at home until urbanization induced state 
governments to confront a problem that had been 
relegated largely to families. The states' response 
was to build institutions, known first as asylums 
and later as mental hospitals. When the 
Pennsylvania Hospital opened in Philadelphia in 
the mid- 18th century, it had provisions for 
individuals with mental illness housed in its 
basement. Also in the mid- 18th century, colonial 
Virginia was the first state to build an asylum for 
mentally ill citizens, which it constructed in its 
capital at Williamsburg. If not cared for at home or 
in asylums, those with mental illness were likely to 
be found in jails, almshouses, work houses, and 
other institutions. By the time of the Revolutionary 
War, the beginnings were in place for each of the 
four sectors of the de facto mental health system. 
The origins of treatment for mental illness in 
the general medical/primary care sector can be 
traced to the Pennsylvania Hospital. The origins of 
specialty mental health care can be traced to the 
Williamsburg asylum. Home care, the most 
common response to mental illness, probably 
became a part of the voluntary support network, 
whereas the human services sector was by far the 
most common organized or institutional response, 
by placing individuals in almshouses (homes for 
the poor) and work houses. The first form of treat- 
ment — known as "moral treatment" — was not given 
until the very end of the 18th century, after the 
Revolutionary War. 



75 



Mental Health: A Report of the Surgeon General 

Figure 2-5a. Annual prevalence of mental/addictive disorders and services for adults 



Percent of Population (28%) With 

Mental/Addictive Disorders 

(in one year) 



Diagnosis and 

No Treatment 

(20%) 




Percent of Population (15%) Receiving 

Mental Health Services* 

(in one year) 



Treatment and No Diagnosis, 

Otiier IVlental Health Problem 

Inferred (7%) 



Diagnosis and Treatment (8%) 



Figure 2-5b. Annual prevalence of mental/addictive disorders and services for adults 



Percent of Population (28%) With 

Mental/Addictive Disorders 

(in one year) 


Percent of Population (15%) Receiving 
Mental Health Services* 
M (in one year) 


/ 


y^ N. ^s. Percent of Population Receiving 
/ 4%** \2%**\ Specialty Care (6%) 


Diagnosis and 


^^ 2°/°** Percent of Population Receiving 
^ •^ General Medical Care (5%) 

\ 1 1 


(20%) 1 


\ \ jij 2%** / Percent of Population Receiving 

\ >in«|2%** 7 / Other Human Services and 

\v ^l|^ y ^^y^ Voluntary Support (4%) 

* Due to rounding, it appears that 9 percent of the population has a diagnosis and receives treatment. The actual 
figure is closer to 8 percent, as stated in the text. It also appears that 6 percent of the population receives 
services but has no diagnosis, due to rounding. The actual total is 7 percent, as stated in the text. 

** For those who use more than one sector of the service system, preferential assignment is to the most 
specialized level of mental health treatment in the system. 

Sources: Regier et al., 1993; Kessler et al., 1996 



76 



The Fundamentals of Mental Health and Mental Illness 

Figure 2-6a. Annual prevalence of mental/addictive disorders and services for children 



Percent of Population (21%) With 

Mental/Addictive Disorders 

(In one year) 



Diagnosis and 

No Treatment 

(11%) 



Percent of Population (21%) Receiving 

Mental Health Services 

(in one year) 




Treatment and No Diagnosis, 

Other Mental Health Problem 

Inferred (11%) 



Diagnosis and Treatment (10%) 



Figure 2-6b. Annual prevalence of mental/addictive disorders and services for children 



Percent of Population (21%) With 

Mental/Addictive Disorders 

(In one year) 



Diagnosis and 

No Treatment 

(11%) 




Percent of Population (21%) Receiving 

IVIental Health Services 

(in one year) 



Percent of Population Receiving 
Specialty Care (8%) 



Percent of Population Receiving 
General Medical Care (1%) 



Percent of Population 

Receiving School 

Services (11%) 



Percent of Population Receiving 

Other Human Services and 

Voluntary Support (1%) 



** For those who use more than one sector of the service system, preferential assignment is to the most 
specialized level of mental health treatment in the system. 

Source: Shaffer et al., 1996 



77 



Mental Health: A Report of the Surgeon General 



An era of "moral treatment" was introduced 
from Europe at the turn of the 19th century, 
representing the first of four reform movements in 
mental health services in the United States 
(Morrissey & Goldman, 1984; Goldman & 
Morrissey, 1985) (Table 2-10). 

The first reformers, including Dorothea Dix and 
Horace Mann, imported the idea that mental illness 
could be treated by removing the individual to an 
asylum to receive a mix of somatic and psychosoci- 
al treatments in a controlled environment 
characterized by "moral" sensibilities. The term 
"moral" had a connotation different from that of 
today. It meant the return of the individual to 
reason by the application of psychologically 
oriented therapy'^ (Grob, 1994). The "moral treat- 
ment" period was characterized by the building of 
private and public asylums. Almost every state had 
an asylum dedicated to the early treatment of 
mental illness to restore mental health and to keep 
patients from becoming chronically ill. Moral 
treatment accomplished the former objective, but it 
could not prevent chronicity. 

Shortly after the Civil War, the failures of the 
promise of early treatment were recognized and 
asylums were built for untreatable, chronic 
patients. The quality of care deteriorated in public 
institutions, where overcrowding and underfunding 
ran rampant. A new reform movement, devoted to 
"mental hygiene," began late in the 19th century. It 
combined the newly emerging concepts of public 
health (which at the time was referred to as 
"hygiene"), scientific medicine, and social 
progressivism. Although the states built the public 
asylums, local government was expected to pay for 
each episode of care. To avoid the expense, many 
communities continued to use local almshouses and 
jails. Asylums could not maintain their budgets, 
care deteriorated, and newspaper exposes revealed 
inhuman conditions both in asylums and local 



" According to a student of the originator of moral treatment, 
Philippe Pinel, "moral treatment is the application of the faculty of 
intelligence and of the emotions in the treatment of mental 
alienation" (Grob, 1994). 



welfare institutions. State Care Acts were passed 
between 1894 and World War I. These acts 
centralized financial responsibility for the care of 
individuals with mental illness in every state 
government. Local government took the 
opportunity to send everyone with a mental illness, 
including dependent older citizens, to the state 
asylums. Dementia was redefined as a mental 
illness, although only some of the older residents 
were demented. For the past century the states have 
carried this responsibility at very low cost, in spite 
of the magnitude of the task. 

The reformers of the "mental hygiene" period, 
who formed the National Committee on Mental 
Hygiene (now the National Mental Health 
Association [NMHA]), called for an expansion of 
the new science, particularly of neuropathology, in 
asylums, which were renamed mental hospitals. 
They also called for "psychopathic hospitals and 
clinics" to bring the new science to patients in 
smaller institutions associated with medical 
schools. They opened several psychiatric units in 
general hospitals to move mental health care into 
the mainstream of health care. The mental 
hygienists believed in the principles of early 
treatment and expected to prevent chronic mental 
illness. To support this effort, they advocated for 
outpatient treatment to identify early cases of 
mental disorder and to follow discharged 
inpatients. 

Treatments were not effective. Early treatment 
was no more successful in preventing patients from 
becoming chronically ill in the early 20th century 
than it was in the early years of the previous 
century. At best, the hospitals provided humane 
custodial care; at worst, they neglected or abused 
the patients. Length of stay did begin to decline for 
newly admitted inpatients, but older, long-stay 
patients filled public asylums. The financial 
problems and overcrowding deepened during the 
Depression and during World War II. 

Enthusiasm for early interventions, developed 
by military mental health services during World 
War II, brought a new sense of optimism about 



78 



The Fundamentals of Mental Health and Mental Illness 



Table 2-10. Historical reform movements in 


mental health treatment in the Un 


ted States 


Reform Movement 


Era 


Setting 


Focus of Reform 


Moral Treatment 


1800-1850 


Asylum 


Humane, restorative treatment 


1 


Mental Hygiene 


1890-1920 


Mental hospital and clinic 


Prevention, scientific 
orientation 


1 


Community Mental Health 


1955-1970 


Community mental health center 


Deinstitutionalization, 
social integration 


J 


Community Support 


1975-present 


Community support 


Mental illness as a social welfare 
problem (e.g., housing, employment) 


1 



Sources: Morrissey & Goldman, 1984; Goldman & Morrissey, 1985 



treatment by the middle of the 20th century. Again, 
early treatment of mental disorders was 
championed and a new concept was born, 
"community mental health." The NMHA figured 
prominently in this reform, along with the Group 
for the Advancement of Psychiatry. Borrowing 
some ideas from the mental hygienists and 
capitalizing on the advent of new drugs for treating 
psychosis and depression, community mental health 
reformers argued that they could bring mental 
health services to the public in their communities. 
They suggested that long-term institutional care in 
mental hospitals had been neglectful, ineffective, 
even harmful. The joint policies of "community 
care" and "deinstitutionalization" led to dramatic 
declines in the length of hospital stay and the 
discharge of many patients from custodial care in 
hospitals. 

Concomitantly, these policies led to the 
expansion of outpatient services in the community, 
particularly in federally funded community mental 
health centers. Federal legislation beginning in the 
mid-1960s fueled this expansion through grants to 
centers and then through the inclusion of some 
(albeit limited) mental health benefits in Medicare 
and Medicaid. The latter was particularly 
important, because it stimulated the transfer of 
many long-term inpatients from public mental 
hospitals to nursing homes, encouraged the opening 



of psychiatric units in general hospitals, and 
ultimately paid for many rehabilitation services for 
individuals with severe and persistent mental 
disorders. 

The dual policies of community care and 
deinstitutionalization, however, were implemented 
without evidence of effectiveness of treatments and 
without a social welfare system attuned to the 
needs of hundreds of thousands of individuals with 
disabling mental illness. Housing, support services, 
community treatment approaches, vocational 
opportunities, and income supports for those unable 
to work were not universally available in the 
community. Neither was there a truly welcoming 
spirit of community support for "returning" mental 
patients. Many discharged mental patients found 
themselves in welfare and criminal justice 
institutions, as had their predecessors in earlier 
eras; some became homeless or lived in regimented 
residential (e.g., board and care) settings in the 
community. 

The special needs of individuals with severe 
and persistent mental illness were not being met 
(General Accounting Office, 1977; Turner & 
TenHoor, 1978). Early treatment did not prevent 
disability, although new approaches to treatment 
would eventually reduce morbidity and improve 
quality of life. A fourth reform era ( 1 975-present), 
called the "community support" movement, grew 



79 



Menta! Health: A Report of the Surgeon General 



directly out of the "community mental health 
movement." This new reform movement called for 
an end to viewing and responding to chronic mental 
disorder only as the object of neglect, by favoring 
acute treatment and prevention. Reformers 
advocated for developing "community support 
systems," with an expanded vision of care and 
treatment as encompassing the social welfare needs 
of individuals with disabling mental illness. The 
emphasis favored the view that individuals could 
once again become citizens of their community, if 
given support and access to mainstream resources 
such as housing and vocational opportunities 
(Goldman, 1998). At first, mental health treatments 
were deemphasized in favor of social supports, but 
newer medications, such as SSRIs and novel anti- 
psychotic drugs, and more effective psychosocial 
interventions, such as assertive community 
treatment for schizophrenia (Chapter 4), facilitated 
the objectives of community support and recovery 
in the community. 

The voluntary support network expanded with 
an emphasis on "recovery," a concept introduced 
by service users, or consumers, who began to take 
an active role in their own care and support and in 
making policy. From their inception in the late 
1970s, family organizations, such as the National 
Alliance for the Mentally 111 and the Federation of 
Families, advocated for services for individuals 
who are most impaired. As discussed later in this 
chapter, consumers, who also call themselves 
"survivors," have formed their own networks for 
support and advocacy and work with other 
advocacy groups such as the National Mental 
Health Association and the Bazelon Center for 
Mental Health Law. 

The de facto mental health system is complex 
because it has metamorphosed over time under the 
influence of a wide array of factors, including 
reform movements and their ideologies, financial 
incentives based on who would pay for what kind 
of services, and advances in care and treatment 
technology. Each factor has been important in its 
own way. The hybrid system that emerged serves 



many diverse functions. Unfortunately for those 
individuals with the most complex needs, and who 
often have the fewest financial resources, the 
system is fragmented and difficult to use to meet 
those needs effectively. Efforts at integrating the 
service system and tailoring it to those with the 
greatest needs are discussed, by age group, in 
subsequent chapters of the report. Many problems 
remain, including the lack of health insurance by 1 6 
percent of the U.S. population, underinsurance for 
mental disorders even among those who have health 
insurance, access barriers to members of many 
racial and ethnic groups, discrimination, and the 
stigma about mental illness, which is one of the 
factors that impedes help-seeking behavior. 

Overview of Cultural Diversity and 
Mental Health Services 

The U.S. mental health system is not well equipped 
to meet the needs of racial and ethnic minority 
populations. Racial and ethnic minority groups are 
generally considered to be underserved by the 
mental health services system (Neighbors et al., 
1992; Takeuchi & Uehara, 1996; Center for Mental 
Health Services [CMHS], 1998). A constellation of 
barriers deters ethnic and racial minority group 
members from seeking treatment, and if individual 
members of groups succeed in accessing services, 
their treatment may be inappropriate to meet their 
needs. 

Awareness of the problem dates back to the 
1960s and 1970s, with the rise of the civil rights 
and community mental health movements (Rogler 
et al., 1987) and with successive waves of 
immigration from Central America, the Caribbean, 
and Asia (Takeuchi & Uehara, 1996). These 
historical forces spurred greater recognition of the 
problems that minority groups confront in relation 
to mental health services. 

Research documents that many members of 
minority groups fear, or feel ill at ease with, the 
mental health system (Lin et al., 1982; Sussman et 
al., 1987; Scheffler & Miller, 1991). These groups 
experience it as the product of white, European 



80 



The Fundamentals of Mental Health and Mental Illness 



culture, shaped by research primarily on white, 
European populations. They may find only 
clinicians who represent a white middle-class 
orientation, with its cultural values and beliefs, as 
well as its biases, misconceptions, and stereotypes 
of other cultures. 

Research and clinical practice have propelled 
advocates and mental health professionals to press 
for "linguistically and culturally competent 
services" to improve utilization and effectiveness 
of treatment for different cultures. Culturally 
competent services incorporate respect for and 
understanding of, ethnic and racial groups, as well 
as their histories, traditions, beliefs, and value 
systems (CMHS, 1998). Without culturally 
competent services, the failure to serve racial and 
ethnic minority groups adequately is expected to 
worsen, given the huge demographic growth in 
these populations predicted over the next decades 
(Takeuchi & Uehara, 1996; CMHS, 1998; 
Snowden, 1999). 

This section of the chapter amplifies these 
major conclusions. It explains the confluence of 
clinical, cultural, organizational, and financial 
reasons for minority groups being underserved by 
the mental health system. The first task, however, 
is to explain which ethnic and racial groups 
constitute underserved populations, to describe 
their changing demographics, and to define the 
term "culture" and its consequences for the mental 
health system. 

Introduction to Cultural Diversity and 
Demographics 

The Federal government officially designates /owr 
major racial or ethnic minority groups in the United 
States: African American (black), Asian/Pacific 
Islander, Hispanic American (Latino), ^° and Native 
American/American Indian/Alaska Native/Native 
Hawaiian (referred to subsequently as "American 
Indians") (CMHS, 1998). There are many other 



^° The term "Latino(a)" refers to all persons of Mexican, Puerto 
Rican, Cuban, or other Central and South American or Spanish 
origin (CMHS, 1998). 



racial or ethnic minorities and considerable 
diversity within each of the four groupings listed 
above. The representation of the four officially 
designated groups in the U.S. population in 1999 is 
as follows: African Americans constitute the 
largest group, at 12.8 percent of the U.S. 
population; followed by Hispanics (1 1.4 percent), 
Asian/Pacific Islanders (4.0 percent), and American 
Indians (0.9 percent) (U.S. Census Bureau, 1999). 
Hispanic Americans are among the fastest-growing 
groups. Because their population growth outpaces 
that of African Americans, they are projected to be 
the predominant minority group (24.5 percent of 
the U.S. population) by the year 2050 (CMHS, 
1998). 

Racial and ethnic populations differ from one 
another and from the larger society with respect to 
culture. The term "culture" is used loosely to 
denote a common heritage and set of beliefs, 
norms, and values. The cultures with which 
members of minority racial and ethnic groups 
identify often are markedly different from 
industrial societies of the West. The phrase 
"cultural identity" specifies a reference group — an 
identifiable social entity with whom a person 
identifies and to whom he or she looks for 
standards of behavior (Cooper & Denner, 1998). Of 
course, within any given group, an individual's 
cultural identity may also involve language, 
country of origin, acculturation,^' gender, age, 
class, religious/spiritual beliefs, sexual 
orientation-^, and physical disabilities (Lu et al., 
1995). Many people have multiple ethnic or 
cultural identities. 

The historical experiences of ethnic and 
minority groups in the United States are reflected 



-' Acculturation refers to the "social distance" separating members 
of an ethnic or racial group from the wider society in areas of beliefs 
and values and primary group relations (work, social clubs, family, 
friends) (Gordon, 1964). Greater acculturation thus reflects greater 
adoption of mainstream beliefs and practices and entry into primary 
group relations. 

-- Research is emerging on the importance of tailoring services to 
the special needs of gay, lesbian, and bisexual mental health service 
users (Cabaj & Stein, 1996). 



81 



Mental Health: A Report of the Surgeon General 



in differences in economic, social, and political 
status. The most measurable difference relates to 
income. Many racial and ethnic minority groups 
have limited financial resources. In 1994, families 
from these groups were at least three times as likely 
as white families to have incomes placing them 
below the Federally established poverty line. The 
disparity is even greater when considering extreme 
poverty — family incomes at a level less than half of 
the poverty threshold — and is also large when 
considering children and older persons (O'Hare, 
1996). Although some Asian Americans are 
somewhat better off financially than other minority 
groups, they still are more than one and a half times 
more likely than whites to live in poverty. Poverty 
disproportionately affects minority women and 
their children (Miranda & Green, 1999). The 
effects of poverty are compounded by differences 
in total value of accumulated assets, or total wealth 
(O'Hare etal., 1991). 

Lower socioeconomic status — in terms of 
income, education, and occupation — has been 
strongly linked to mental illness. It has been known 
for decades that people in the lowest 
socioeconomic strata are about two and a half times 
more likely than those in the highest strata to have 
a mental disorder (Holzer et al., 1986; Regier et al., 
1993b). The reasons for the association between 
lower socioeconomic status and mental illness are 
not well understood. It may be that a combination 
of greater stress in the lives of the poor and greater 
vulnerability to a variety of stressors leads to some 
mental disorders, such as depression. Poor women, 
for example, experience more frequent, threatening, 
and uncontrollable life events than do members of 
the population at large (Belle, 1990). It also may be 
that the impairments associated with mental 
disorders lead to lower socioeconomic status 
(McLeod & Kessler, 1990; Dohrenwend, 1992; 
Regier etal., 1993b). 

Cultural identity imparts distinct patterns of 
beliefs and practices that have implications for the 
willingness to seek, and the ability to respond to, 



mental health services. These include coping styles 
and ties to family and community, discussed below. 

Coping Styles 

Cultural differences can be reflected in differences 
in preferred styles of coping with day-to-day 
problems. Consistent with a cultural emphasis on 
restraint, certain Asian American groups, for 
example, encourage a tendency not to dwell on 
morbid or upsetting thoughts, believing that 
avoidance of troubling internal events is warranted 
more than recognition and outward expression 
(Leong & Lau, 1998). They have little willingness 
to behave in a fashion that might disrupt social 
harmony (Uba, 1994). Theiremphasis on willpower 
is similar to the tendency documented among 
African Americans to minimize the significance of 
stress and, relatedly, to try to prevail in the face of 
adversity through increased striving (Broman, 
1996). 

Culturally rooted traditions of religious beliefs 
and practices carry important consequences for 
willingness to seek mental health services. In many 
traditional societies, mental health problems can be 
viewed as spiritual concerns and as occasions to 
renew one's commitment to a religious or spiritual 
system of belief and to engage in prescribed 
religious or spiritual forms of practice. African 
Americans (Broman, 1996) and a number of ethnic 
groups (Lu et al., 1995), when faced with personal 
difficulties, have been shown to seek guidance from 
religious figures.-^ 

Many people of all racial and ethnic 
backgrounds believe that religion and spirituality 
favorably impact upon their lives and that well- 
being, good health, and religious commitment or 
faith are integrally intertwined (Taylor, 1986; 
Priest, 1991; Bacote, 1994; Pargament, 1997). 
Religion and spirituality are deemed important 
because they can provide comfort, joy, pleasure, 
and meaning to life as well as be means to deal 



" Of the 15 percent of the U.S. population that use mental health 
services in a given year, about 2.8 percent receive care only from 
members of the clergy (Larson et al., 1988). 



82 



The Fundamentals of Mental Health and Mental Illness 



with death, suffering, pain, injustice, tragedy, and 
stressful experiences in the life of an individual or 
family (Pargament, 1997). In the family/com- 
munity-centered perception of mental illness held 
by Asians and Hispanics, religious organizations 
are viewed as an enhancement or substitute when 
the family is unable to cope or assist with the 
problem (Acosta et al., 1982; Comas-Diaz, 1989; 
Cook & Timberlake, 1989; Meadows, 1997). 

Culture also imprints mental health by 
influencing whether and how individuals 
experience the discomfort associated with mental 
illness. When conveyed by tradition and sanctioned 
by cultural norms, characteristic modes of 
expressing suffering are sometimes called "idioms 
of distress" (Lu et al., 1995). Idioms of distress 
often reflect values and themes found in the 
societies in which they originate. 

One of the most common idioms of distress is 
somatization, the expression of mental distress in 
terms of physical suffering. Somatization occurs 
widely and is believed to be especially prevalent 
among persons from a number of ethnic minority 
backgrounds (Lu et al., 1995). Epidemiological 
studies have confirmed that there are relatively 
high rates of somatization among African 
Americans (Zhang & Snowden, in press). Indeed, 
somatization resembles an African American folk 
disorder identified in ethnographic research and is 
linked to seeking treatment (Snowden, 1998). 

A number of idioms of distress are well 
recognized as culture-bound syndromes and have 
been included in an appendix to DSM-IV. Among 
culture-bound syndromes found among some Latino 
psychiatric patients is ataque de nervios, a 
syndrome of "uncontrollable shouting, crying, 
trembling, and aggression typically triggered by a 
stressful event involving family. . . " (Lu et al., 
1995, p. 489). A Japanese culture-bound syndrome 
has appeared in that country ' s clinical modification 
of ICD-10 (WHO International Classification of 
Diseases, 10th edition, 1993). Taijin kyofusho is an 
intense fear that one's body or bodily functions 
give offense to others. Culture-bound syndromes 



sometimes reflect comprehensive systems of belief , 
typically emphasizing a need for a balance between 
opposing forces (e.g., yin/yang, "hot-cold" theory) 
or the power of supernatural forces (Cheung & 
Snowden, 1990). Belief in indigenous disorders and 
adherence to culturally rooted coping practices are 
more common among older adults and among 
persons who are less acculturated. It is not well 
known how applicable DSM-IV diagnostic criteria 
are to culturally specific symptom expression and 
culture-bound syndromes. 

Family and Community as Resources 

Ties to family and community, especially strong in 
African, Latino, Asian, and Native American 
communities, are forged by cultural tradition and 
by the current and historical need to assist arriving 
immigrants, to provide a sanctuary against 
discrimination practiced by the larger society, and 
to provide a sense of belonging and affirming a 
centrally held cultural or ethnic identity. 

Among Mexican-Americans (del Pinal & 
Singer, 1997) and Asian Americans (Lee, 1998) 
relatively high rates of marriage and low rates of 
divorce, along with a greater tendency to live in 
extended family households, indicate an orientation 
toward family. Family solidarity has been invoked 
to explain relatively low rates among minority 
groups of placing older people in nursing homes 
(Short et al., 1994). 

The relative economic success of Chinese, 
Japanese, and Korean Americans has been 
attributed to family and communal bonds of 
association (Fukuyama, 1995). Community 
organizations and networks established in the 
United States include rotating credit associations 
based on lineage, surname, or region of origin. 
These organizations and networks facilitate the 
startup of small businesses. 

There is evidence of an African American 
tradition of voluntary organizations and clubs often 
having political, economic, and social functions 
and affiliation with religious organizations 
(Milburn & Bowman, 1991). African Americans 



83 



Mental Health: A Report of the Surgeon General 



and other racial and ethnic minority groups have 
drawn upon an extended family tradition in which 
material and emotional resources are brought to 
bear from a number of linked households. 
According to this literature, there is "(a) a high 
degree of geographical propinquity; (b) a strong 
sense of family and familial obligation; (c) fluidity 
of household boundaries, with greater willingness 
to absorb relatives, both real and fictive, adult and 
minor, if need arises; (d) frequent interaction with 
relatives; (e) frequent extended family get- 
togethers for special occasions and holidays; and 
(f) a system of mutual aid" (Hatchett & Jackson, 
1993, p. 92). 

Families play an important role in providing 
support to individuals with mental health problems. 
A strong sense of family loyalty means that, despite 
feelings of stigma and shame, families are an early 
and important source of assistance in efforts to 
cope, and that minority families may expect to 
continue to be involved in the treatment of a 
mentally ill member (Uba, 1994). Among Mexican 
American families, researchers have found lower 
levels of expressed emotion and lower levels of 
relapse (Karno et al., 1987). Other investigators 
have demonstrated an association between family 
warmth and a reduced likelihood of relapse (Lopez 
et al., in press). 

Epidemiology and Utilization of Services 

One of the best ways to identify whether a minority 
group has problems accessing mental health 
services is to examine their utilization of services 
in relation to their need for services. As noted 
previously, a limitation of contemporary mental 
health knowledge is the lack of standard measures 
of "need for treatment" and culturally appropriate 
assessment tools. Minority group members' needs, 
as measured indirectly by their prevalence of 
mental illness in relation to the U.S. population, 
should be proportional to their utilization, as 
measured by their representation in the treatment 
population. These comparisons turn out to be 
exceedingly complicated by inadequate under- 



standing of the prevalence of mental disorders 
among minority groups in the United States. ^"^ 
Nationwide studies conducted many years ago 
overlooked institutional populations, which are 
disproportionately represented by minority groups. 
Treatment utilization information on minority 
groups in relation to whites is more plentiful, yet, 
a clear understanding of health seeking behavior in 
various cultures is lacking. 

The following paragraphs reveal that disparities 
abound in treatment utilization: some minority 
groups are underrepresented in the outpatient 
treatment population while, at the same time, 
overrepresented in the inpatient population. 
Possible explanations for the differences in utili- 
zation are discussed in a later section. 

African Americans 

The prevalence of mental disorders is estimated to 
be higher among African Americans than among 
whites (Regier et al., 1993a). This difference does 
not appear to be due to intrinsic differences 
between the races; rather, it appears to be due to 
socioeconomic differences. When socioeconomic 
factors are taken into account, the prevalence 
difference disappears. That is, the socioeconomic 
status-adjusted rates of mental disorder among 
African Americans turn out to be the same as those 
of whites. In other words, it is the lower 
socioeconomic status of African Americans that 
places them at higher risk for mental disorders 
(Regier et al., 1993a). 

African Americans are underrepresented in 
some outpatient treatment populations, but over- 
represented in public inpatient psychiatric care in 
relation to whites (Snowden & Cheung, 1990; 



-" In spring 2000, survey field work begins on an NIMH-funded 
study of the prevalence of mental disorders, mental health 
symptoms, and related functional impairments in African 
Americans, Caribbean blacks, and non-Hispanic whites. The study 
will examine the effects of psychosocial factors and race-associated 
stress on mental health, and how coping resources and strategies 
influence that impact. The study will provide a database on mental 
health, mental disorders, and ethnicity and race. James Jackson, 
Ph.D., University of Michigan, is principal investigator. 



84 



The Fundamentals of Mental Health and Mental Illness 



Snowden, in press-b). Their underrepresentation in 
outpatient treatment varies according to setting, 
type of provider, and source of payment. The racial 
gap between African Americans and whites in 
utilization is smallest, if not nonexistent, in com- 
munity-based programs and in treatment financed 
by public sources, especially Medicaid (Snowden, 
1998) and among older people (Padgett et al., 
1995). The underrepresentation is largest in 
privately financed care, especially individual 
outpatient practice, paid for either by fee-for- 
service arrangements or managed care. As a result, 
underrepresentation in the outpatient setting occurs 
more among working and middle-class African 
Americans, who are privately insured, than among 
the poor. This suggests that socioeconomic 
standing alone cannot explain the problem of 
underutilization (Snowden, 1998). 

African Americans are, as noted above, 
overrepresented in inpatient psychiatric care 
(Snowden, in press-b). Their rate of utilization of 
psychiatric inpatient care is about double that of 
whites (Snowden & Cheung, 1990). This difference 
is even higher than would be expected on the basis 
of prevalence estimates. Overrepresentation is 
found in hospitals of all types except private 
psychiatric hospitals."^ While difficult to explain 
definitively, the problem of overrepresentation in 
psychiatric hospitals appears more rooted in 
poverty, attitudes about seeking help, and a lack of 
community support than in clinician bias in 
diagnosis and overt racism, which also have been 
implicated (Snowden, in press-b). This line of 
reasoning posits that poverty, disinclination to seek 
help, and lack of health and mental health services 
deemed appropriate, and responsive, as well as 
community support, are major contributors to 
delays by African Americans in seeking treatment 
until symptoms become so severe that they warrant 
inpatient care. 



Finally, African Americans are more likely than 
whites to use the emergency room for mental health 
problems (Snowden, in press-a). Their overreliance 
on emergency care for mental health problems is an 
extension of their overreliance on emergency care 
for other health problems. The practice of using the 
emergency room for routine care is generally 
attributed to a lack of health care providers in the 
community willing to offer routine treatment to 
people without insurance (Snowden, in press-a). 

Asian Americans/Pacific Islanders 

The prevalence of mental illness among Asian 
Americans is difficult to determine for 
methodological reasons (i.e., population sampling). 
Although some studies suggest higher rates of 
mental illness, there is wide variance across 
different groups of Asian Americans (Takeuchi & 
Uehara, 1996). It is not well known how applicable 
DSM-IV diagnostic criteria are to culturally 
specific symptom expression and culture-bound 
syndromes. With respect to treatment-seeking 
behavior, Asian Americans are distinguished by 
extremely low levels at which specialty treatment 
is sought for mental health problems (Leong & Lau, 
1998). Asian Americans have proven less likely 
than whites, African Americans, and Hispanic 
Americans to seek care. One national sample 
revealed that Asian Americans were only a quarter 
as likely as whites, and half as likely as African 
Americans and Hispanic Americans, to have sought 
outpatient treatment (Snowden, in press-a). Asian 
Americans/Pacific Islanders are less likely than 
whites to be psychiatric inpatients (Snowden & 
Cheung, 1990). The reasons for the underutilization 
of services include the stigma and loss of face over 
mental health problems, limited English 
proficiency among some Asian immigrants, 
different cultural explanations for the problems, 
and the inability to find culturally competent ser- 
vices. These phenomena are more pronounced for 
recent immigrants (Sue et al., 1994). 



■' African Americans are overrepresented among persons 
undergoing involuntary civil commitment (Snowden, in press-b). 



85 



Mental Health: A Report of the Surgeon General 



Hispanic Americans 

Several epidemiological studies revealed few 
differences between Hispanic Americans and 
whites in lifetime rates of mental illness (Robins & 
Regier, 1991; Vega & Kolody, 1998). A recent 
study of Mexican Americans in Fresno County, 
California, found that Mexican Americans born in 
the United States had rates of mental disorders 
similar to those of other U.S. citizens, whereas 
immigrants born in Mexico had lower rates (Vega 
et al., 1998a). A large study conducted in Puerto 
Rico reported similar rates of mental disorders 
among residents of that island, compared with those 
of citizens of the mainland United States (Canino et 
al., 1987). 

Although rates of mental illness may be similar 
to whites in general, the prevalence of particular 
mental health problems, the manifestation of 
symptoms, and help-seeking behaviors within 
Hispanic subgroups need attention and further 
research. For instance, the prevalence of depressive 
symptomatology is higher in Hispanic women 
(46%) than men (almost 20%); yet, the known risk 
factors do not totally explain the gender difference 
(Vega et al., 1998a; Zunzunegui et al., 1998). 
Several studies indicate that Puerto Rican and 
Mexican American women with depressive 
symptomatology are underrepresented in mental 
health services and overrepresented in general 
medical services (Hough et al., 1987; Sue et al., 
1991, 1994; Duran, 1995; Jimenez et al., 1997). 

Native Americans 

American Indians/Alaska Natives have, like Asian 
Americans and Pacific Islanders, been studied in 
few epidemiological surveys of mental health and 
mental disorders. The indications are that 
depression is a significant problem in many 
American Indian/Alaska Native communities 
(Nelson et al., 1992). One study of a Northwest 
Indian village found rates of DSM-III-R affective 
disorder that were notably higher than rates 
reported from national epidemiological studies 
(Kinzie et al., 1992). Alcohol abuse and 



dependence appear also to be especially 
problematic, occurring at perhaps twice the rate of 
occurrence found in any other population group. 
Relatedly, suicide occurs at alarmingly high levels. 
(Indian Health Service, 1997). Among Native 
American veterans, post-traumatic stress disorder 
has been identified as especially prevalent in 
relation to whites (Manson, 1998). In terms of 
patterns of utilization. Native Americans are 
overrepresented in psychiatric inpatient care in 
relation to whites, with the exception of private 
psychiatric hospitals (Snowden & Cheung, 1990; 
Snowden, in press-b). 

Barriers to the Receipt of Treatment 

The underrepresentation in outpatient treatment of 
racial and ethnic minority groups appears to be the 
result of cultural differences as well as financial, 
organizational, and diagnostic factors. The service 
system has not been designed to respond to the 
cultural and linguistic needs presented by many 
racial and ethnic minorities. What is unresolved are 
the relative contribution and significance of each 
factor for distinct minority groups. 

Help-Seeking Beiiavior 

Among adults, the evidence is considerable that 
persons from minority backgrounds are less likely 
than are whites to seek outpatient treatment in the 
specialty mental health sector (Sussman et al., 
1987; Gallo et al., 1995; Leong & Lau, 1998; 
Snowden, 1998; Vega et al., 1998a, 1998b; Zhang 
et al., 1998). This is not the case for emergency 
department care, from which African Americans 
are more likely than whites to seek care for mental 
health problems, as noted above. Language, like 
economic and accessibility differences, can play an 
important role in why people from other cultures do 
not seek treatment (Hunt, 1984; Comas-Diaz, 1989; 
Cook & Timberlake, 1989; Taylor, 1989). 

Mistrust 

The reasons why racial and ethnic minority groups 
are less apt to seek help appear to be best studied 



86 



The Fundamentals of Mental Health and Mental Illness 



among African Americans. By comparison with 
whites, African Americans are more likely to give 
the following reasons for not seeking professional 
help in the face of depression: lack of time, fear of 
hospitalization, and fear of treatment (Sussman et 
al., 1987). Mistrust among African Americans may 
stem from their experiences of segregation, racism, 
and discrimination (Primm et al., 1996; Priest, 
1991). African Americans have experienced racist 
slights in their contacts with the mental health 
system, called "microinsults" by Pierce (1992). 
Some of these concerns are justified on the basis of 
research, cited below, revealing clinician bias in 
overdiagnosis of schizophrenia and underdiagnosis 
of depression among African Americans. 

Lack of trust is likely to operate among other 
minority groups, according to research about their 
attitudes toward government-operated institutions 
rather than toward mental health treatment per se. 
This is particularly pronounced for immigrant 
families with relatives who may be undocumented, 
and hence they are less likely to trust authorities 
for fear of being reported and having the family 
member deported. People from El Salvador and 
Argentina who have experienced imprisonment or 
watched the government murder family members 
and engage in other atrocities may have an 
especially strong mistrust of any governmental 
authority (Garcia & Rodriguez, 1989). Within the 
Asian community, previous refugee experiences of 
groups such as Vietnamese, Indochinese, and 
Cambodian immigrants parallel those experienced 
by Salvadoran and Argentine immigrants. They, 
too, experienced imprisonment, death of family 
members or friends, physical abuse, and assault, as 
well as new stresses upon arriving in the United 
States (Cook & Timberlake, 1989; Mollica, 1989). 

American Indians' past experience in this 
country also imparted lack of trust of government. 
Those living on Indian reservations are particularly 
fearful of sharing any information with white 
clinicians employed by the government. As with 
African Americans, the historical relationship of 
forced control, segregation, racism, and 



discrimination has affected their ability to trust a 
white majority population (Herring, 1994; 
Thompson, 1997). 

Stigma 

The stigma of mental illness is another factor 
preventing African Americans from seeking 
treatment, but not at a rate significantly different 
from that of whites. Both African American and 
white groups report that embarrassment hinders 
them from seeking treatment (Sussman et al., 
1987). In general, African Americans tend to deny 
the threat of mental illness and strive to overcome 
mental health problems through self-reliance and 
determination (Snowden, 1998). Stigma, denial, 
and self-reliance are likely explanations why other 
minority groups do not seek treatment, but their 
contribution has not been evaluated empirically, 
owing in part to the difficulty of conducting this 
type of research. One of the few studies of Asian 
Americans identified the barriers of stigma, 
suspiciousness, and a lack of awareness about the 
availability of services (Uba, 1994). Cultural 
factors tend to encourage the use of family, 
traditional healers, and informal sources of care 
rather than treatment-seeking behavior, as noted 
earlier. 

Cost 

Cost is yet another factor discouraging utilization 
of mental health services (Chapter 6). Minority 
persons are less likely than whites to have private 
health insurance, but this factor alone may have 
little bearing on access. Public sources of insurance 
and publicly supported treatment programs fill 
some of the gap. Even among working class and 
middle-class African Americans who have private 
health insurance, there is underrepresentation of 
African Americans in outpatient treatment 
(Snowden, 1998). Yet studies focusing only on 
poor women, most of whom were members of 
minority groups, have found cost and lack of 
insurance to be barriers to treatment (Miranda & 
Green, 1999). The discrepancies in findings suggest 



87 



Mental Health: A Report of the Surgeon General 



that much research remains to be performed on the 
relative importance of cost, cultural, and 
organizational barriers, and poverty and income 
limitations across the spectrum of racial and ethnic 
and minority groups. 

Clinician Bias 

Advocates and experts alike have asserted that bias 
in clinician judgment is one of the reasons for 
overutilization of inpatient treatment by African 
Americans. Bias in clinician judgment is thought to 
be reflected in overdiagnosis or misdiagnosis of 
mental disorders. Since diagnosis is heavily reliant 
on behavioral signs and patients' reporting of the 
symptoms, rather than on laboratory tests, clinician 
judgment plays an enormous role in the diagnosis 
of mental disorders. The strongest evidence of 
clinician bias is apparent for African Americans 
with schizophrenia and depression. Several studies 
found that African Americans were more likely 
than were whites to be diagnosed with 
schizophrenia, yet less likely to be diagnosed with 
depression (Snowden & Cheung, 1990; Hu et al., 
1991;Lawsonetal., 1994). 

In addition to problems of overdiagnosis or 
misdiagnosis, there may well be a problem of 
underdiagnosis among minority groups, such as 
Asian Americans, who are seen as "problem-free" 
(Takeuchi & Uehara, 1996). The presence and 
extent of this type of clinician bias are not known 
and need to be investigated. 

Improving Treatment for Minority 
Groups 

The previous paragraphs have documented 
underutilization of treatment, less help-seeking 
behavior, inappropriate diagnosis, and other 
problems that have beset racial and ethnic minority 
groups with respect to mental health treatment. 
This kind of evidence has fueled the widespread 
perception of mental health treatment as being 
uninviting, inappropriate, or not as effective for 
minority groups as for whites. The Schizophrenia 
Patient Outcome Research Team demonstrated that 



African Americans were less likely than others to 
have received treatment that conformed to 
recommended practices (Lehman & Steinwachs, 
1998). Inferior treatment outcomes are widely 
assumed but are difficult to prove, especially 
because of sampling, questionnaire, and other 
design issues, as well as problems in studying 
patients who drop out of treatment after one session 
or who otherwise terminate prematurely. In a 
classic study, 50 percent of Asian Americans versus 
30 percent of whites dropped out of treatment early 
(Sue & McKinney, 1 975). However, the disparity in 
dropout rates may have abated more recently 
(O'Sullivan et al., 1989; Snowden et al., 1989). 
One of the few studies of clinical outcomes, a pre- 
versus post-treatment study, found that African 
Americans fared more poorly than did other 
minority groups treated as outpatients in the Los 
Angeles area (Sue et al., 1991). Earlier studies from 
the 1970s and 1980s had given inconsistent results 
(Sueetal., 1991). 

Ethnopsychopharmacology 

There is mounting awareness that ethnic and 
cultural influences can alter an individual's 
responses to medications (pharmacotherapies). The 
relatively new field of ethnopsychopharmacology 
investigates cultural variations and differences that 
influence the effectiveness of pharmacotherapies 
used in the mental health field. These differences 
are both genetic and psychosocial in nature. They 
range from genetic variations in drug metabolism to 
cultural practices that affect diet, medication 
adherence, placebo effect, and simultaneous use of 
traditional and alternative healing methods (Lin et 
al., 1997). Just a few examples are provided to 
illustrate ethnic and racial differences. 

Pharmacotherapies given by mouth usually 
enter the circulation after absorption from the 
stomach. From the circulation they are distributed 
throughout the body (including the brain for 
psychoactive drugs) and then metabolized, usually 
in the liver, before they are cleared and eliminated 
from the body (Brody, 1994). The rate of 



88 



The Fundamentals of Mental Health and Mental Illness 



metabolism affects the amount of the drug in the 
circulation. A slow rate of metabolism leaves more 
drug in the circulation. Too much drug in the 
circulation typically leads to heightened side 
effects. A fast rate of metabolism, on the other 
hand, leaves less drug in the circulation. Too little 
drug in the circulation reduces its effectiveness. 

There is wide racial and ethnic variation in drug 
metabolism. This is due to genetic variations in 
drug-metabolizing enzymes (which are responsible 
for breaking down drugs in the liver) . These genetic 
variations alter the activity of several drug- 
metabolizing enzymes. Each drug-metabolizing 
enzyme normally breaks down not just one type of 
pharmacotherapy, but usually several types. Since 
most of the ethnic variation comes in the form of 
inactivation or reduction in activity in the enzymes, 
the result is higher amounts of medication in the 
blood, triggering untoward side effects. 

For example, 33 percent of African Americans 
and 37 percent of Asians are slow metabolizers of 
several antipsychotic medications and 
antidepressants (such as tricyclic antidepressants 
and selective serotonin reuptake inhibitors) (Lin et 
al., 1997). This awareness should lead to more 
cautious prescribing practices, which usually entail 
starting patients at lower doses in the beginning of 
treatment. Unfortunately, just the opposite typically 
had been the case with African American patients 
and antipsychotic drugs. Clinicians in psychiatric 
emergency services prescribed more oral doses and 
more injections of antipsychotic medications to 
African American patients (Segel et al., 1996). The 
combination of slow metabolism and overmedica- 
tion of antipsychotic drugs in African Americans 
can yield very uncomfortable extrapyramidal^^ side 
effects (Lin et al., 1997). These are the kinds of 
experiences that likely contribute to the mistrust of 
mental health services reported among African 
Americans (Sussman et al., 1987). 



^^ Dystonia (brief or prolonged contraction of muscles), akathisia 
(an urge to move about constantly), or parkinsonism (tremor and 
rigidity) (Perry et al., 1997). 



Psychosocial factors also can play an important 
role in ethnic variation. Compliance with dosing 
may be hindered by communication difficulties; 
side effects can be misinterpreted or carry different 
connotations; some groups may be more responsive 
to placebo treatment; and reliance on psychoactive 
traditional and alternative healing methods (such as 
medicinal plants and herbs) may result in 
interactions with prescribed pharmacotherapies. 
The result could be greater side effects and 
enhanced or reduced effectiveness of the 
pharmacotherapy, depending on the agents involved 
and their concentrations (Lin et al., 1997). Greater 
awareness of ethnopsychopharmacology is 
expected to improve treatment effectiveness for 
racial and ethnic minorities. More research is 
needed on this topic across racial and ethnic 
groups. 

Minority-Oriented Services 

Through employment of minority practitioners and 
the creation of specialized minority-oriented 
programs, community-based, publicly supported 
mental health programs have achieved greater 
minority representation than are found in other 
mental health settings (Snowden, 1999). Mental 
health care providers who are themselves from 
ethnic minority backgrounds are especially likely to 
treat ethnic minority clients and have been found to 
enjoy good success in retaining them in treatment 
(Sueetal., 1991). 

The character of the mental health program in 
which treatment is provided has proven particularly 
important in encouraging minority mental health 
service use. Research has shown that programs that 
specialize in serving identified minority 
communities have been successful in encouraging 
minorities to enter and remain in treatment (Yeh et 
al., 1994; Snowden et al., 1995; Takeuchi et al., 
1995; Snowden &Hu, 1996). Modeled on programs 
successfully targeting groups of recent immigrants 
and refugees, minority-oriented programs appear to 
succeed by maintaining active, committed 
relationships with community institutions and 



89 



Mental Health: A Report of the Surgeon General 



leaders and making aggressive outreach efforts; by 
maintaining a familiar and welcoming atmosphere; 
and by identifying and encouraging styles of 
practice best suited to the problems particular to 
racial and ethnic minority group members. A 
challenge for such programs is to meet specialized 
sociocultural needs for clients from various 
backgrounds. The track record of minority-oriented 
programs at improving treatment outcomes is not 
yet clear for adults but appears to be positive for 
children and adolescents (Yeh et al., 1994). 

There is a specialized system of care for Native 
Americans that provides mental health treatment. 
The Indian Health Service (IHS) includes a Mental 
Health Programs Branch; it offers mental health 
treatment intended to be culturally appropriate. 
Urban Indian Health Programs also provide for 
mental health treatment. The IHS Alcohol- 
ism/Substance Abuse Program Branch sponsors 
services on reservations and in urban communities 
through contracts with service providers. Most 
mental health programs in the IHS focus on 
screening and treatment in primary care settings. 
Due to budgetary restraints, IHS is able to provide 
only limited medical, including mental health, 
coverage of Native American peoples (Manson, 
1998). 

Many tribes have moved toward self- 
determination and, as a result, toward assuming 
direct control of local programs. When surveyed, 
these tribal health programs reported providing 
mental health care in a substantial number of 
instances, although questions remain about the 
nature and scope of services. Finally, the 
Department of Veterans Affairs and many state and 
local authorities provide specialized mental health 
programming targeting persons of Native American 
heritage (Manson, 1998). Little is known about the 
levels and types of care provided under any of these 
arrangements. 



Cultural Competence 

Advocates and policymakers have called for all 
mental health practitioners to be culturally 
competent: to recognize and to respond to cultural 
concerns of ethnic and racial groups, including 
their histories, traditions, beliefs, and value 
systems (CMHS, 1998). 

Cultural competence is one approach to helping 
mental health service systems and professionals 
create better services and ensure their adequate 
utilization by diverse populations (Cross et al., 
1989). It is defined as a set of behaviors, attitudes, 
and policies that come together in a system or 
agency or among professionals that enables that 
system, agency, or professionals to work 
effectively in cross-cultural situations (Cross et al., 
1989). This is especially important because most 
mental health providers are not racial and ethnic 
minority group members (Hernandez et al., 1998). 
Using the term "competence" places the 
responsibility on the mental health services 
organization and all of its employees, challenging 
them all to become part of a process of providing 
culturally appropriate services. This approach 
emphasizes understanding the importance of 
culture and building service systems that recognize, 
incorporate, practice, and value cultural diversity. 

There is no single prescribed method for 
accomplishing cultural competence. It begins with 
respect, and not taking an ethnocentric perspective 
about behavior, values, or beliefs. Three possible 
methods are to render mainstream treatments more 
inviting and accessible to minority groups through 
enhanced communication and greater awareness; to 
select a traditional therapeutic approach according 
to the perceived needs of the minority group; or to 
adapt available therapeutic approaches to the needs 
of the minority group (Rogler et al., 1987). One 
effort to promote cultural competence has been 
directed toward mental health services systems 
and programs. The Center for Mental Health 
Services has developed, with national input, a 
preliminary set of performance indicators for 
"cultural competence" by which service and 



90 



The Fundamentals of Mental Health and Mental Illness 



funding organizations might be judged. Cultural 
competence in this context includes consultation 
with cross-cultural experts and training of staff, a 
capacity to provide services in languages other than 
English, and the monitoring of caseloads to ensure 
proportional racial and ethnic representation. The 
ultimate test of any performance indicator will be 
documented by improvements in care and treatment 
of ethnic and racial minorities. 

Another response has been to develop 
guidelines that more directly convey variations 
believed necessary in the course of clinical 
practice. An appendix to DSM-IV presents 
clinicians with an Outline for Cultural Formulation. 
The guidelines are intended as a supplement to 
standard diagnosis, for use in multicultural environ- 
ments and for the provision of a "systematic review 
of the individual's cultural background, the role of 
the cultural context in the expression and 
evaluation of symptoms and dysfunction, and the 
effect that cultural differences may have on the 
relationship between the individual and the 
clinician" (DSM-IV). 

The Outline for Cultural Formulation covers 
several areas. It calls for an assessment of cultural 
identity, including degree of involvement with 
alternative cultural reference groups; cultural 
explanations of illness; cultural factors related to 
stresses, supports, and level of functioning and 
disability (e.g., religion, kin networks); differences 
in culture or social status between patient and 
clinician and possible barriers (e.g., communi- 
cation, trust); and overall cultural assessment. 

Others have focused attention on the process by 
which mental health practitioners must engage, 
assess, and treat patients and on understanding how 
cultural differences might affect that process 
(Lopez et al., in press). Viewed from this 
perspective, the task is to maintain two points of 
view — that of the cultural group and that of 
evidence-based mental health practice — and 
strategically integrate them with the aim of valuing 
and utilizing culture, context, and practice in a way 
that promotes mental health. 



This capacity has a dual advantage. The 
practitioner comes to understand the problem as it 
is experienced and understood by the patient and, 
in so doing, gains otherwise inaccessible 
information on personal and social reality for the 
patient, as well as a sense of trust and credibility. 
At the same time the practitioner is able to plan for 
and implement an appropriate intervention. It is 
through a facility and a willingness to switch from 
a professional orientation to that of the client and 
his or her cultural group that the clinician is best 
able to implement guidelines for cultural 
competence such as those specified in DSM-IV 
(Mezzich et al., 1996). 

In the end, to be culturally competent is to 
deliver treatment that is equally effective to all 
sociocultural groups. The treatments provided must 
not only be efficacious (based on clinical research), 
but also effective in community delivery. The 
delivery of effective treatments is complicated 
because most research on efficacy has been 
conducted on predominantly white populations. 
This suggests the importance of both efficacy and 
effectiveness studies on racial and ethnic 
minorities. 

At present, there is scant knowledge about 
treatment effectiveness according to race, culture, 
or ethnicity (Snowden & Hu, 1996). Rarely has 
research evaluating standard forms of treatment 
examined differential effectiveness. In fact, the 
American Psychological Association's Division of 
Clinical Psychology Task Force, which tried to 
identify the efficacy of different psychotherapeutic 
treatments, could not find a single rigorous study of 
treatment efficacy published on ethnic minority 
clients (Chambless et al., 1996). Nor have studies 
been carried out on the efficacy of proposed 
cultural adaptations of treatment in comparison 
with standard alternatives. Only as more knowledge 
is gained will it become possible to mount a full- 
fledged and appropriate response to racial and 
ethnic differences in the provision of mental health 
care. 



91 



Mental Health: A Report of the Surgeon General 



Rural Mental Health Services 

The differences between rural and urban communi- 
ties present another source of diversity in mental 
health services. People in rural America encounter 
numerous barriers to the receipt of effective 
services. Some barriers are geographic, created by 
the problem of delivering services in less densely 
populated rural areas and even more sparsely 
populated frontier areas. Some barriers are 
"cultural," insofar as rural America reflects a range 
of cultures and life styles that are distinct from 
urban life. Urban culture and its approach to 
delivering mental health services dominate mental 
health services (Beeson et al., 1998). 

Rural America is shrinking in size and political 
influence (Danbom, 1995; Dyer, 1997). As a 
consequence, rural mental health services do not 
figure prominently in mental health policy (Ahr & 
Holcomb, 1985; Kimmel, 1992). Furthermore, rural 
economies are in decline, and the population is 
decreasing in most areas (yet expanding rapidly in 
a few boom areas) (Hannan, 1998). Rural America 
is no longer a stable or homogeneous environment. 
The farm crisis of the 1980s unleashed a period of 
economic hardship and rapid social change, 
adversely affecting the mental health of the 
population (Ortega et al., 1994; Hoyt et al., 1995). 

Policies and programs designed for urban 
mental health services often are not appropriate for 
rural mental health services (Beeson et al., 1998). 
Beeson and his colleagues (1998) list a host of 
important differences that should be considered in 
designing rural mental health services. In an era of 
specialized services, rural mental health relies 
heavily on primary medical care and social 
services. Stigma is particularly intense in rural 
communities, where anonymity is difficult to 
maintain (Hoyt et al., 1997). In an era of expanding 
private mental health services, rural mental health 
services have been predominantly publicly funded. 
Consumer and family involvement in advocacy, 
characteristic of urban and suburban areas, is rare 
in rural America. The supply of services and 
providers is limited, so choice is constrained. 



Mental health services in rural areas cannot achieve 
certain economies of scale, and some state-of-the 
art services (e.g., assertive community treatment) 
are inefficient to deliver unless there is a critical 
mass of patients. Informal supports and indigenous 
healers assume more importance in rural mental 
health care. 

Rural mental health concerns are being raised 
nationally (Rauch, 1997; Ciarlo, 1998; Beeson et 
al., 1998). Model programs offer new designs for 
services (Mohatt & Kirwan, 1995), particularly 
through the integration of mental health and 
primary care (Bird et al., 1995, 1998; Size, 1998). 
Newer technology, such as advanced tele- 
communications in the form of "telemental health," 
may improve rural access to expertise from 
professionals located in urban areas (Britain, 1996; 
La Mendola, 1997; Smith & Allison, 1998). 
Internet access, videoconferencing, and various 
computer applications offer an opportunity to 
enhance the quality of care in rural mental health 
services. 

Overview of Consumer and Family 
Movements 

Since the late 1970s, mental health services 
continue to be transformed by the growing 
influence of consumer and family organizations 
(Lefley, 1996). Through strong advocacy, consumer 
and family organizations have gained a voice in 
legislation and policy for mental health service 
delivery. Organizations representing consumers and 
family members, though divergent in their 
historical origins and philosophy, have developed 
some important, overlapping goals: overcoming 
stigma and preventing discrimination, promoting 
self-help groups, and promoting recovery from 
mental illness (Frese, 1998). 

This section covers the history, goals, and 
impact of consumer and family organizations, 
whereas the next section covers the process of 
recovery from mental illness. With literally 
hundreds of grassroots consumer organizations 
across the United States, no single organization 



92 



The Fundamentals of Mental Health and Mental Illness 



speaks for all consumers or all families. In fact, 
even the term "consumer" is not uniformly 
accepted. Despite the heterogeneity, these 
organizations typically offer some combination of 
advocacy and self-help groups (Lefley, 1996). 

Many users of mental health services refer 
to themselves as "consumers." The lexicon is 
complicated by objections to the term "consumer." 
To some, being a consumer erroneously signifies 
that service users have the power to choose services 
most suitable to their needs. Those who object 
contend that consumers have neither choices, 
leverage, nor power to select services. Instead, 
some consumers refer to themselves as "survivors" 
or "ex-patients" to denote that they have survived 
what they experienced as oppression by the mental 
health system (Chamberlin & Rogers, 1990). This 
distinction can best be understood in its historical 
context. 

Origins and Goals of Consumer Groups 

The consumer movement arose as a protest in the 
1970s by former patients of mental hospitals. Their 
antecedents trace back to the 19th century, when a 
handful of individuals recovered enough to write 
exposes expressing their outrage at the indignities 
and abuses inside mental hospitals. The most 
persuasive former patient was Clifford Beers, 
whose classic book, A Mind That Found Itself 
(1908), galvanized the mental hygiene reform 
movement (Grob, 1994). Beers was among the 
founders of the National Committee on Mental 
Hygiene, an advocacy group that later was renamed 
the National Mental Health Association. This group 
focuses on linking citizens and mental health 
professionals in broad-based prevention of mental 
illness. 

With the advent of deinstitutionalization in the 
1950s, increasing numbers of former patients of 
mental hospitals began to forge informal ties in the 
community. By the 1960s, the civil rights move- 
ment inspired former patients to become better 
organized into what was then coined the mental 
patients' liberation movement (Chamberlin, 1995). 



Groups of patients saw themselves as having been 
rejected by society and robbed of power and 
control over their lives. To surmount what they saw 
as persecution, they began to advocate for self- 
determination and basic rights (Chamberlin, 1990; 
Frese & Davis, 1997). The posture of these early 
groups was decidedly militant against psychiatry, 
against laws favoring involuntary commitment, and 
often against interventions such as electroconvul- 
sive therapy and antipsychotic medications (Lefley, 
1996; Frese, 1998). Groups called Alliance for the 
Liberation of Mental Patients, the Insane Liberation 
Front, and Project Release met in homes and 
churches, drawing their membership from those 
with firsthand experiences with the mental health 
system. Largely unfunded, they sustained their 
membership by providing peer support, education 
about services in the community, and advocacy to 
help members access services and to press for 
reforms (Furlong-Norman, 1988). 

The book On Our Own (1978) by former patient 
Judi Chamberlin was a benchmark in the history of 
the consumer movement. Consumers and others 
were able to read in the mainstream press what it 
was like to have experienced the mental health 
system. For many consumers, reading this book was 
the beginning of their involvement in consumer 
organizations (Van Tosh & del Vecchio, in press). 
Early consumer groups, although geographically 
dispersed, voluntary, and independent, were linked 
through the newsletter Madness Network News, 
which continued publication from 1972 to 1986. 
During the same era, the Conference on Human 
Rights and Against Psychiatric Oppression was 
established and met annually from 1973 through 
1985 (Chamberlin, 1990). In 1978, early consumer 
groups gained what they perceived as their first 
official acknowledgment from the highest levels of 
government. The President's Commission on 
Mental Health stated that ". . . groups composed of 
individuals with mental or emotional problems are 
being formed all over the United States" 
(President's Commission on Mental Health, 1978, 
pp. 14-15). To date, racial and ethnic minority 



93 



Mental Health: A Report of the Surgeon General 



group members are underrepresented within the 
consumer movement proportionate to their growing 
representation in the U.S. population. There is a 
need for more outreach and involvement of 
consumers representing the special concerns of 
racial and ethnic minorities. 

The advocacy positions of consumers have 
dealt with the role of involuntary treatment, self- 
managed care, the role of consumers in research, 
the delivery of services, and access to mental health 
services. By 1985, consumer views became so 
divergent that two groups emerged: The National 
Association of Mental Patients^^ and the National 
Mental Health Consumers' Association. The former 
opposed all forms of involuntary treatment, 
supported the prohibition of electroconvulsive 
therapy, and rejected psychotropic medications and 
hospitalization. The latter organization held more 
moderate views for improving rather than 
eschewing the mental health service system 
(Lefley. 1996;Frese, 1998). Both groups eventually 
disbanded, but the differences of opinion that they 
reflected became deeply entrenched. 

Self-Help Groups 

Self-help refers to groups led by peers to promote 
mutual support, education, and growth (Lefley, 
1996). Self-help is predicated on the belief that 
individuals who share the same health problem can 
help themselves and each other to cope with their 
condition. The self-help approach enjoys a long 
history, most notably with the formation of 
Alcoholics Anonymous in 1935 (lOM, 1990). Over 
time, the self-help approach has been brought to 
virtually every conceivable health condition. 

Since the 1970s, many mental health consumer 
groups emphasized self-help as well as advocacy 
(Chamberlin, 1995), although to different degrees. 
Self-help for recovering mental patients initially 
emphasized no involvement with mental health 
professionals. Over time the numbers and types of 



^' Later renamed the National Association of Psychiatric Survivors 
(Chamberlin, 1995). 



self-help groups began to flourish and more 
moderate viewpoints became represented. Self-help 
groups assume three different postures toward 
health professionals: the separatist model, the 
supportive model that allows professionals to aid in 
auxiliary roles, and partnership models in which 
professionals act as leaders alongside patients 
(Chamberlin, 1978; Emerick, 1990). The focus of 
groups varies, with some groups united on the basis 
of diagnosis, such as Schizophrenics Anonymous 
and the National Depressive and Manic-Depressive 
Association, whereas others are more broad based. 

Chamberlin' s influential book and another book 
by former patients, Reaching Across (Zinman et al., 
1987), explained to consumers how to form self- 
help groups. These books also extended the concept 
of self-help more broadly into the provision of 
consumer-run services as alternatives (as opposed 
to adjuncts) to mental health treatment (Lefley, 
1996). 

Programs entirely run by consumers include 
drop-in centers, case management programs, 
outreach programs, businesses, employment and 
housing programs, and crisis services (Long & Van 
Tosh, 1988; National Resource Center on 
Homelessness and Mental Illness, 1989; Van Tosh 
& del Vecchio, in press). Drop-in centers are places 
for consumers to obtain social support and 
assistance with problems. Although research is 
limited, the efficacy of consumer-run services is 
discussed in Chapter 4. 

Consumer positions also are being incorporated 
into more conventional mental health services — as 
job coaches and case manager extenders, among 
others. The rationale for employing consumers in 
service delivery — in consumer-run or conventional 
programs — is to benefit those hired and those 
served. Consumers who are hired obtain 
employment, enhance self-esteem, gain work 
experience and skills, and sensitize other service 
providers to the needs of people with mental 
disorders. Consumers who are served may be more 
receptive to care and have role models engaged in 
their care (Mowbray et al., 1996). 



94 



The Fundamentals of Mental Health and Mental Illness 



Accomplishments of Consumer 
Organizations 

Consumer organizations have had measurable 
impact on mental health services, legislation, and 
research. One of their greatest contributions has 
been the organization and proliferation of self-help 
groups and their impact on the lives of thousands of 
consumers of mental health services. In 1993, a 
collaborative survey found that 46 state mental 
health departments funded 567 self-help groups and 
agencies for persons with mental disabilities and 
their family members (National Association of 
State Mental Health Program Directors, 1993). A 
nationwide directory lists all 50 states and the 
District of Columbia as having 235 different mental 
health consumer organizations (South Carolina 
SHARE, 1995). 

On a systems level, the consumer movement has 
substantially influenced mental health policy to 
tailor services to consumer needs. This influence is 
described by consumers and researchers as 
"empowerment." A concept from the social 
sciences, empowerment has come to be defined by 
mental health researchers as "gaining control over 
one's life in influencing the organizational and 
societal structures in which one lives" (Segal et al., 
1995). 

Consumers are now involved in all aspects of 
the planning, delivery, and evaluation of mental 
health services, and in the protection of individual 
rights. One prominent example is the passage of 
Public Law 102-321, which established mental 
health planning councils in every state. Planning 
councils are required to have membership from 
consumers and families. Having a planning council 
so constituted is required for the receipt of Federal 
block grant funds for mental health services. Other 
Federal legislation required the establishment of 
protection and advocacy agencies for patients' 
rights in every state (Chamberlin & Rogers, 1990; 
Lefley, 1996). 

Another significant development has been the 
establishment of offices of consumer affairs in 
many state mental health authorities. Offices of 



consumer affairs are generally staffed by 
consumers to support consumer empowerment and 
self-help in their particular states. A recent survey 
of state mental health authorities identified 27 
states as having paid positions for consumers in 
central offices (Geller et al., 1998). In 1995, the 
Federal Center for Mental Health Services hired its 
first consumer affairs specialist. 

The consumer movement also has had a 
substantial influence on increasing the utilization 
of consumers as employees in the traditional mental 
health system, as well as in other human service 
agencies (Specht, 1988; U.S. Department of 
Education, 1990; Schlageter, 1990; Interagency 
Council on the Homeless, 1991). Consumers are 
being hired at all levels in the mental health 
system, ranging from case manager aides to 
management positions in national advocacy 
organizations, as well as state and Federal 
governmental agencies. 

Finally, consumers continue to be involved in 
research in several ways: ?i'& participants of clinical 
research; as respondents who are asked questions 
about conditions in their life; as partners in some 
aspect of the planning, designing, and conducting 
of the research project with professional 
researchers in control; and as independent 
researchers who conduct, analyze the data, and 
publish the results of the research project 
(Campbell et al., 1993). The past decade has 
witnessed the blossoming of a vibrant consumer 
research agenda and the growing belief that 
consumer involvement in research and evaluation 
holds great promise for system reform, quality 
improvement, and outcome measurement (Campbell 
et al., 1993; Campbell, 1997). In an effort to 
enhance the active role of consumers and others in 
the research process, the National Institute of 
Mental Health is developing a systematic means of 
including public participants in the initial review of 
grant applications in the areas of clinical treatment 
and services research. This innovation follows up 
on a recommendation made by the Institute of 



95 



Mental Health: A Report of the Surgeon General 



Medicine and Committee for the Study of the 
Future of Public Health (1988). 

Family Advocacy 

The family movement has experienced spectacular 
growth and influence since its beginnings in the 
late 1970s (Lefley, 1996). Although several 
advocacy and professional organizations speak to 
the needs of families, the family movement is 
principally represented by three large 
organizations. They are the National Alliance for 
the Mentally 111 (NAMI), the Federation of Families 
for Children's Mental Health (FFCMH), and the 
National Mental Health Association (NMHA). 
NAMI serves families of adults with chronic mental 
illness, whereas the Federation serves children and 
youth with emotional, behavioral, or mental 
disorders. NMHA serves a broad base of family 
members and other supporters of children and 
adults with mental disorders and mental health 
problems. Though the target populations are 
different, these organizations are similar in their 
devotion to advocacy, family support, research, and 
public awareness. 

Fragmentation and lack of availability of 
services were motivating forces behind the 
establishment of the family movement. 
Deinstitutionalization, in particular, was a cogent 
impetus for the formation of NAMI. 
Deinstitutionalization of the mentally ill left 
families in the unexpected position of having to 
assume care for their adult children, a role for 
which they were ill prepared. Another motivating 
force behind the family movement was the past 
tendency by the mental health establishment to 
blame parents for the mental illness in children 
(Frese, 1998). The cause of schizophrenia, for 
example, had been attributed to the 
"schizophrenogenic mother," who was cold and 
aloof, according to a reigning but now discredited 
view of etiology. Similarly, parents were viewed as 
partly to blame for children with serious emotional 
or behavioral disturbances (Melaville & Asayesh 
1993; Friesen & Stephens, 1998). 



NAMI was created as a grassroots organization 
in 1979 by a small cadre of families in Madison, 
Wisconsin. Since then, its membership has 
skyrocketed to 208,000 in all 50 states (NAMI, 
1999). NAMI's principal goal is to advocate for 
improved services for persons with severe and 
persistent mental illness — for example, 
schizophrenia and bipolar disorder. Its sole 
emphasis on the most severely affected consumers 
distinguishes it from most other consumer and 
family organizations. Another NAMI goal is to 
transform public attitudes and reduce stigma by 
emphasizing the biological basis of serious mental 
disorders, as opposed to poor parenting (Frese, 
1998; NAMI, 1999). Correspondingly, NAMI 
advocates for intensification of research in the 
neurosciences. Through state and local affiliates, 
NAMI operates a network of family groups for self- 
help and education purposes. 

NAMI's accomplishments are formidable. The 
organization has become a powerful voice for the 
expansion of community-based services to fulfill 
the vision of the community support reform 
movement. NAMI has successfully pressed for 
Federal legislation for family membership in state 
mental health planning boards. It is a prime force 
behind congressional legislation for parity in the 
financing of mental health services. It also has 
made substantial inroads in the training of mental 
health professionals to sensitize them to the 
predicament of the chronically mentally ill. It has 
promoted "psychoeducation," specific information 
to family members, usually in small-group settings, 
about schizophrenia and about strategies for 
dealing with relatives with schizophrenia (Lamb, 
1994). Finally, NAMI has successfully lobbied for 
increased Federal research funding, and it has set 
up private research foundations (Lefley, 1996). 

Similarly, advocacy by parents on behalf of 
children with serious emotional or behavioral 
disturbances has had a compelling impact. 
Advocacy for children was electrified by the 
publication of Jane Knitzer's 1982 book, 
Unclaimed Children; shortly afterward, the 



96 



The Fundamentals of Mental Health and Mental Illness 



National Mental Health Association (NMHA) 
issued Invisible Children (NMHA, 1983), followed 
by A Guide for Advocates to All Systems Failure 
(NMHA, 1993). Knitzer chronicled the plight of 
families in trying to access care from disparate and 
uncoordinated public agencies, many of which 
blamed or ignored parents. NMHA, a pioneer in the 
mental health advocacy field, assumed a pivotal 
role in strengthening the child mental health 
movement in the 1980s and early 1990s. Over time, 
the Federation of Families for Children's Mental 
Health has become another focal point for families, 
championing family participation and support in 
systems of care and access to services. The 
Federation' s chapters across the United States offer 
self-help, education, and networking (FFCMH, 
1999). Through the efforts of these groups and 
individuals, among the most noteworthy 
accomplishments of the family movement has been 
the emergence of family participation in 
decisionmaking about care for children, one of the 
decisive historical shifts in service delivery in the 
past 20 years. 

Overview of Recovery 

Until recently, some severe mental disorders were 
generally considered to be marked by lifelong 
deterioration. Schizophrenia, for instance, was seen 
by the mental health profession as having a 
uniformly downhill course (Harding et al., 1992). 
At the beginning of the 20th century, the leading 
psychiatrist of the era, Emil Kraepelin, judged the 
outcome of schizophrenia to be so dismal that he 
named the disorder "dementia praecox," or 
premature dementia. Negative conceptions of 
severe mental illness, perpetuated in textbooks for 
decades by Kraepelin' s original writings, dampened 
consumers' and families' expectations, leaving 
them without hope. A turnabout in attitudes came 
as a result of the consumer movement and self-help 
activities. They mobilized a shift toward a more 
positive set of consumer attitudes and self- 
perceptions. Research provided a scientific basis 
for and supported a more optimistic view of the 



possibility of recovering function (Harding et al., 
1992). Promoting recovery became a rallying point 
and common ground for the consumer and family 
movements (Frese, 1998). 

The concept of recovery is having substantial 
impact on consumers and families, mental health 
research, and service delivery. Before describing 
that impact, this section first turns to an 
introduction and definitions. 

Introduction and Definitions 

Recovery is a concept introduced in the lay 
writings of consumers beginning in the 1980s. It 
was inspired by consumers who had themselves 
recovered to the extent that they were able to write 
about their experiences of coping with symptoms, 
getting better, and gaining an identity (Deegan, 
1988; Leete, 1989). Recovery also was fueled by 
longitudinal research uncovering a more positive 
course for a significant number of patients with 
severe mental illness (Harding et al., 1992), 
although findings across several studies were 
variable (Harrow et al., 1997) (see discussion in 
Chapter 4). 

Recovery is variously called a process, an 
outlook, a vision, a guiding principle. There is 
neither a single agreed-upon definition of recovery 
nor a single way to measure it. But the overarching 
message is that hope and restoration of a 
meaningful life are possible, despite serious mental 
illness (Deegan, 1988; Anthony, 1993; Stocks, 
1995; Spaniol et al., 1997). Instead of focusing 
primarily on symptom relief, as the medical model 
dictates, recovery casts a much wider spotlight on 
restoration of self-esteem and identity and on 
attaining meaningful roles in society. 

Written testimonials by former mental patients 
have appeared for centuries. These writings, 
according to historian of medicine Roy Porter, 
"shore up that sense of personhood and identity 
which they feel is eroded by society and 
psychiatry" (Porter, 1987). What distinguishes the 
contemporary wave of writings is their critical 
mass, organizational backing, and freedom of 



97 



Mental Health: A Report of the Surgeon General 



expression from outside the confines of the 
institution. Deinstitutionalization, the emergence of 
community supports and psychosocial rehabili- 
tation, and the growth of the consumer and family 
advocacy movements all paved the way for 
recovery to take hold (Anthony, 1993). 

The concept of recovery continues to be defined 
in the writings of consumers (see Figure 2-7). 
These lay writings offer a range of possible 
definitions, many of which seek to discover 
meaning, purpose, and hope from having mental 
illness (Lefley, 1996). The definitions do not, 
however, imply full recovery, in which full 
functioning is restored and no medications are 
needed. Instead they suggest a journey or process, 
not a destination or cure (Deegan, 1997). One of 
the most prominent professional proponents of 
recovery, William A. Anthony, crystallized con- 
sumer writings on recovery with the following 
definition: 

. . . a person with mental illness can 

recover even though the illness is not 

"cured" .... [Recovery] is a way of living 

a satisfying, hopeful, and contributing life 

even with the limitations caused by illness. 

Recovery involves the development of new 

meaning and purpose in one's life as one 

grows beyond the catastrophic effects of 

mental illness {Anthony, 1993). 

It is important to point out that consumers see 

a distinction between recovery and psychosocial 

rehabilitation. The latter, which is discussed more 

extensively in Chapter 4, refers to professional 

mental health services that bring together 

approaches from the rehabilitation and the mental 

health fields (Cook et al., 1996). These services 

combine pharmacological treatment, skills training, 

and psychological and social support to clients and 

families in order to improve their lives and 

functional capacities. Recovery, by contrast, does 

not refer to any specific services. Rather, according 

to the writings of pioneering consumer Patricia 

Deegan, recovery refers to the "lived experience" 



Figure 2-7. Definitions of recovery from 
consumer writings 



Recovery is a process, a way of life, an attitude, 
and a way of approaching the day's challenges. It 
is not a perfectly linear process. At times our 
course is erratic and we falter, slide back, regroup 
and start again. . . . The need is to meet the 
challenge of the disability and to re-establish a 
new and valued sense of integrity and purpose 
within and beyond the limits of the disability; the 
aspiration Is to live, work, and love in a community 
in which one makes a significant contribution 
(Deegan, 1988, p. 15). 

One of the elements that makes recovery possible 
is the regaining of one's belief in oneself 
(Chamberlin, 1997, p. 9). 

Having some hope is crucial to recovery; none of 
us would strive If we believed It a futile effort. . .1 
believe that if we confront our Illnesses with 
courage and struggle with our symptoms 
persistently, we can overcome our handicaps to 
live independently, learn skills, and contribute to 
society, the society that has traditionally 
abandoned us {Leete, 1989, p. 32). 

A recovery paradigm is each person's unique 
experience of their road to recovery. . . .My 
recovery paradigm Included my re-connection 
which included the following four key ingredients: 
connection, safety, hope, and acknowledgment of 
my spiritual self {Long, 1994, p. 4). 

To return renewed with an enriched perspective of 
the human condition is the major benefit of 
recovery. To return at peace, with yourself, your 
experience, your world, and your God, is the major 
joy of recovery {Granger, 1994, p. 10). 



of gaining a new and valued sense of self and of 
purpose (Deegan, 1988). 

Impact of the Recovery Concept 

The impact of the recovery concept is felt most by 
consumers and families. Consumers and families 
are energized by the message of hope and self- 
determination. Having more active roles in 



98 



The Fundamentals of Mental Health and Mental Illness 



treatment, research, social and vocational 
functioning, and personal growth strikes a 
responsive cord. Consumers' harboring more 
optimistic attitudes and expectations may improve 
the course of their illness, based on related research 
from the field of psychosocial and vocational 
rehabilitation (see Chapter 4). Yet direct empirical 
support for the salutary, long-term effect of 
positive expectations, on both consumers and 
families, is still in its infancy (Lefley, 1997). 

The recovery concept likewise is having a 
bearing on mental health research and services. 
Researchers are beginning to study consumer 
attitudes and behavior to attempt to identify the 
elements contributing to recovery. Though still at 
an early stage, research is being driven by 
consumer perspectives on recovery. Consumers 
assert that the recovery process is governed by 
internal factors (their psychological perceptions 
and expectations), external factors (social 
supports), and the ability to self-manage care, all of 
which interact to give them mastery over their 
lives. The first systematic efforts to define 
consumer perceptions of recovery was conducted 
by consumers. The Weil-Being Project, sponsored 
by the California Department of Mental Health, 
was a landmark effort in which mental health 
consumers conducted a multifaceted study to define 
and explore factors promoting or deterring the well- 
being of persons diagnosed with serious mental 
illness (Campbell & Schraiber, 1989). Using 
quantitative survey research, focus groups, and oral 
histories, Campbell (1993) arrived at a definition of 
recovery that incorporates "good health, good food, 
and a decent place to live, all supported by an 
adequate income that is earned through meaningful 
work. We need adequate resources and a satisfying 
social life to meet our desires for comfort and 
intimacy. Well-being is enriched by creativity, a 
satisfying spiritual and sexual life, and a sense of 
happiness" (p. 28). 

Through semistructured interviews with 
consumers about recovery, a subsequent study 
identified the most common factors associated with 



their success in dealing with a mental illness. They 
included medication, community support/case 
management, self-will/self-monitoring, vocational 
activity (including school), and spirituality 
(Sullivan, 1994). Other researchers, also using 
semistructured interviews, suggested that the 
rediscovery and reconstruction of a sense of self 
were important to recovery (Davidson & Strauss, 
1992). 

These early forays by researchers set the stage 
for consumer-driven research efforts to identify 
some of the aspects of recovery. A group of 
consumers with consultant researchers developed 
the Empowerment Scale (Rogers et al., 1997). After 
testing a 28-item scale on members of six self-help 
programs in six states, factor analysis revealed the 
underlying dimensions of empowerment to be 
( 1 ) self-efficacy-self-esteem; (2) power-powerless- 
ness ; (3) community activism; (4) righteous anger; 
and (5) optimism-control over the future. Other 
instruments, found to have consistency and 
construct validity, are the Personal Empowerment 
Scale, the Organizational Empowerment Scale, and 
the Extra-Organizational Empowerment Scale 
(Segal etal., 1995). 

Mental health services continue to be refined 
and shaped by the consumer and recovery 
emphasis. The most tangible changes in services 
come from assertive community treatment and 
psychosocial and vocational rehabilitation, which 
emphasize an array of approaches to maximize 
functioning and promote recovery. Consumer 
interest in self-help and recovery has stimulated the 
proliferation of interventions for what has been 
called "illness management" or "self-managed 
care" for relapse prevention of psychotic 
symptoms. Illness management training programs 
now teach individuals to identify early warning 
signs of relapse and to develop strategies for their 
prevention. All of these transformations in service 
delivery and research affirming their benefits are 
discussed at length in Chapter 4. 

Champions of recovery assert that its greatest 
impact will be on mental health providers and the 



99 



Mental Health: A Report of the Surgeon General 



future design of the service system. They envision 
services being structured to be recovery-oriented to 
ensure that recovery takes place. They envision 
mental health professionals believing in and 
supporting consumers in their quest to recover. In 
a groundbreaking article, William A. Anthony 
described recovery as a guiding vision that "pulls 
the field of services into the future. A vision is not 
reflective of what we are currently achieving, but 
of what we hope for and dream of achieving. 
Visionary thinking does not raise unrealistic 
expectations. A vision begets not false promises but 
a passion for what we are doing." 

Conclusions 

The past 25 years have been marked by several 
discrete, defining trends in the mental health field. 
These have included: 

1. The extraordinary pace and productivity of 
scientific research on the brain and behavior; 

2. The introduction of a range of effective 
treatments for most mental disorders; 

3. A dramatic transformation of our society's 
approaches to the organization and financing of 
mental health care; and 

4. The emergence of powerful consumer and 
family movements. 

Scientific Research. The brain has emerged as 
the central focus for studies of mental health and 
mental illness. New scientific disciplines, 
technologies, and insights have begun to weave a 
seamless picture of the way in which the brain 
mediates the influence of biological, psychological, 
and social factors on human thought, behavior, and 
emotion in health and in illness. Molecular and 
cellular biology and molecular genetics, which are 
complemented by sophisticated cognitive and 
behavioral science, are preeminent research 
disciplines in the contemporary neuroscience of 
mental health. These disciplines are affording 
unprecedented opportunities for "bottom-up" 
studies of the brain. This term refers to research 
that is examining the workings of the brain at the 
most fundamental levels. Studies focus, for 



example, on the complex neurochemical activity 
that occurs within individual nerve cells, or 
neurons, to process information; on the properties 
and roles of proteins that are expressed, or 
produced, by a person's genes; and on the 
interaction of genes with diverse environmental 
influences. All of these activities now are 
understood, with increasing clarity, to underlie 
learning, memory, the experience of emotion, and, 
when these processes go awry, the occurrence of 
mental illness or a mental health problem. 

Equally important to the mental health field is 
"top-down" research; here, as the term suggests, the 
aim is to understand the broader behavioral context 
of the brain's cellular and molecular activity and to 
learn how individual neurons work together in 
well-delineated neural circuits to perform mental 
functions. 

Effective Treatments. As information accumu- 
lates about the basic workings of the brain, it is the 
task of translational research to transfer new 
knowledge into clinically relevant questions and 
targets of research opportunity — to discover, for 
example, what specific properties of a neural 
circuit might make it receptive to safer, more 
effective medications. To elaborate on this 
example, theories derived from knowledge about 
basic brain mechanisms are being wedded more 
closely to brain imaging tools such as functional 
Magnetic Resonance Imaging (MRI) that can 
observe actual brain activity. Such a collaboration 
would permit investigators to monitor the specific 
protein molecules intended as the "targets" of a 
new medication to treat a mental illness or, indeed, 
to determine how to optimize the effect on the brain 
of the learning achieved through psychotherapy. 

In its entirety, the new "integrative neuro- 
science" of mental health offers a way to 
circumvent the antiquated split between the mind 
and the body that historically has hampered mental 
health research. It also makes it possible to 
examine scientifically many of the important 
psychological and behavioral theories regarding 
normal development and mental illness that have 



100 



The Fundamentals of Mental Health and Mental Illness 



been developed in years past. The unswerving goal 
of mental health research is to develop and refine 
clinical treatments as well as preventive inter- 
ventions that are based on an understanding of 
specific mechanisms that can contribute to or lead 
to illness but also can protect and enhance mental 
health. 

Mental health clinical research encompasses 
studies that involve human participants, conducted, 
for example, to test the efficacy of a new treatment. 
A noteworthy feature of contemporary clinical 
research is the new emphasis being placed on 
studying the effectiveness of interventions in actual 
practice settings. Information obtained from such 
studies increasingly provides the foundation for 
services research concerned with the cost, cost- 
effectiveness, and "deliverability" of interventions 
and the design — including economic consider- 
ations — of service delivery systems. 

Organization and Financing of Mental Health 
Care. Another of the defining trends has been the 
transformation of the mental illness treatment and 
mental health services landscapes, including 
increased reliance on primary health care and other 
human service providers. Today, the U.S. mental 
health system is multifaceted and complex, 
comprising the public and private sectors, general 
health and specialty mental health providers, and 
social services, housing, criminal justice, and 
educational agencies. These agencies do not always 
function in a coordinated manner. Its configuration 
reflects necessary responses to a broad array of 
factors including reform movements, financial 
incentives based on who pays for what kind of 
services, and advances in care and treatment 
technology. Although the hybrid system that exists 
today serves diverse functions well for many 
people, individuals with the most complex needs 
and the fewest financial resources often find the 
system fragmented and difficult to use. A challenge 
for the Nation in the near-term future is to speed 
the transfer of new evidence-based treatments and 
prevention interventions into diverse service 
delivery settings and systems, while ensuring 



greater coordination among these settings and 
systems. 

Consumer and Family Movements. The emerg- 
ence of vital consumer and family movements 
promises to shape the direction and complexion of 
mental health programs for many years to come. 
Although divergent in their historical origins and 
philosophy, organizations representing consumers 
and family members have promoted important, 
often overlapping goals and have invigorated the 
fields of research as well as treatment and service 
delivery design. Among the principal goals shared 
by much of the consumer movement are to 
overcome stigma and prevent discrimination in 
policies affecting persons with mental illness; to 
encourage self-help and a focus on recovery from 
mental illness; and to draw attention to the special 
needs associated with a particular disorder or 
disability, as well as by age or gender or by the 
racial and cultural identity of those who have 
mental illness. 

Chapter 2 of the report was written to provide 
background information that would help persons 
from outside the mental health field better 
understand topics addressed in subsequent chapters 
of the report. Although the chapter is meant to 
serve as a mental health primer, its depth of 
discussion supports a range of conclusions: 

1. The multifaceted complexity of the brain is 
fully consistent with the fact that it supports all 
behavior and mental life. Proceeding from an 
acknowledgment that all psychological 
experiences are recorded ultimately in the brain 
and that all psychological phenomena reflect 
biological processes, the modern neuroscience 
of mental health offers an enriched 
understanding of the inseparability of human 
experience, brain, and mind. 

2. Mental functions, which are disturbed in mental 
disorders, are mediated by the brain. In the 
process of transforming human experience into 
physical events, the brain undergoes changes in 
its cellular structure and function. 



101 



Mental Health: A Report of the Surgeon General 



3 . Few lesions or physiologic abnormalities define 
the mental disorders, and for the most part their 
causes remain unknown. Mental disorders, 
instead, are defined by signs, symptoms, and 
functional impairments. 

4. Diagnoses of mental disorders made using 
specific criteria are as reliable as those for 
general medical disorders. 

5. About one in five Americans experiences a 
mental disorder in the course of a year. 
Approximately 15 percent of all adults who 
have a mental disorder in one year also 
experience a co-occurring substance (alcohol or 
other drug) use disorder, which complicates 
treatment. 

6. A range of treatments of well-documented 
efficacy exists for most mental disorders. Two 
broad types of intervention include psycho- 
social treatments — for example, psycho- 
therapy or counseling — and psychopharma- 
cologic treatments; these often are most 
effective when combined. 

7. In the mental health field, progress in 
developing preventive interventions has been 
slow because, for most major mental disorders, 
there is insufficient understanding about 
etiology (or causes of illness) and/or there is an 
inability to alter the known etiology of a 
particular disorder. Still, some successful 
strategies have emerged in the absence of a full 
understanding of etiology. 

8. About 10 percent of the U.S. adult population 
uses mental health services in the health sector 
in any year, with another 5 percent seeking 
such services from social service agencies, 
schools, religious, or self-help groups. Yet 
critical gaps exist between those who need 
service and those who receive service. 

9. Gaps also exist between optimally effective 
treatment and what many individuals receive in 
actual practice settings. 

10. Mental illness and less severe mental health 
problems must be understood in a social and 
cultural context, and mental health services 



must be designed and delivered in a manner 
that is sensitive to the perspectives and needs 
of racial and ethnic minorities. 

11. The consumer movement has increased the 
involvement of individuals with mental 
disorders and their families in mutual support 
services, consumer-run services, and advocacy. 
They are powerful agents for changes in service 
programs and policy. 

12. The notion of recovery reflects renewed 
optimism about the outcomes of mental illness, 
including that achieved through an individual's 
own self-care efforts, and the opportunities 
open to persons with mental illness to 
participate to the full extent of their interests in 
the community of their choice. 

Mental Health and Mental Illness Across 
the Lifespan 

The Surgeon General's report takes a lifespan 
approach to its consideration of mental health and 
mental illness. Three chapters that address, 
respectively, the periods of childhood and 
adolescence, adulthood, and later adult life 
beginning somewhere between ages 55 and 65, 
capture the contributions of research to the breadth, 
depth, and vibrancy that characterize all facets of 
the contemporary mental health field. 

The disorders featured in depth in Chapters 3, 
4, and 5 were selected on the basis of the frequency 
with which they occur in our society, and the 
clinical, societal, and economic burden associated 
with each. To the extent that data permit, the report 
takes note of how gender and culture, in addition to 
age, influence the diagnosis, course, and treatment 
of mental illness. The chapters also note the 
changing role of consumers and families, with 
attention to informal support services (i.e., unpaid 
services), with which many consumers are 
comfortable and upon which they depend for 
information. Persons with mental illness and, often, 
their families welcome a proliferating array of 
support services — such as self-help programs, 
family self-help, crisis services, and advocacy — 



102 



The Fundamentals of Mental Health and Mental Illness 



that help them cope with the isolation, family 
disruption, and possible loss of employment and 
housing that may accompany mental disorders. 
Support services can help to dissipate stigma and to 
guide patients into formal care as well. 

Mental health and mental illness are dynamic, 
ever-changing phenomena. At any given moment, 
a person's mental status reflects the sum total of 
that individual's genetic inheritance and life 
experiences. The brain interacts with and re- 
sponds — both in its function and in its very 
structure — to multiple influences continuously, 
across every stage of life. At different stages, 
variability in expression of mental health and 
mental illness can be very subtle or very pro- 
nounced. As an example, the symptoms of 
separation anxiety are normal in early childhood 
but are signs of distress in later childhood and 
beyond. It is all too common for people to 
appreciate the impact of developmental processes 
in children, yet not to extend that conceptual 
understanding to older people. In fact, people 
continue to develop and change throughout life. 
Different stages of life are associated with 
vulnerability to distinct forms of mental and 
behavioral disorders but also with distinctive 
capacities for mental health. 

Even more than is true for adults, children must 
be seen in the context of their social 
environments — that is, family and peer group, as 
well as that of their larger physical and cultural 
surroundings. Childhood mental health is expressed 
in this context, as children proceed along the arc of 
development. A great deal of contemporary 
research focuses on developmental processes, with 
the aim of understanding and predicting the forces 
that will keep children and adolescents mentally 
healthy and maintain them on course to become 
mentally healthy adults. Research also focuses on 
identifying what factors place some at risk for 
mental illness and, yet again, what protects some 
children but not others despite exposure to the 
same risk factors. In addition to studies of normal 
development and of risk factors, much research 



focuses on mental disorders in childhood and 
adolescence and what can be done to prevent or 
treat these conditions and on the design and 
operation of service settings best suited to the 
needs experienced by children. 

For about one in five Americans, adulthood — a 
time for achieving productive vocations and for 
sustaining close relationships at home and in the 
community — is interrupted by mental illness. 
Understanding why and how mental disorders occur 
in adulthood, often with no apparent portents of 
illness in earlier years, draws heavily on the full 
panoply of research conducted under the aegis of 
the mental health field. In years past, the onset, or 
occurrence, of mental illness in the adult years, was 
attributed principally to observable phenomena — 
for example, the burden of stresses associated with 
career or family, or the inheritance of a disease 
viewed to run in a particular family. Such 
explanations now may appear naive at best. 

Contemporary studies of the brain and behavior 
are racing to fill in the picture by elucidating 
specific neurobiological and genetic mechanisms 
that are the platform upon which a person's life 
experiences can either strengthen mental health or 
lead to mental illness. It now is recognized that 
factors that influence brain development prenatally 
may set the stage for a vulnerability to illness that 
may lie dormant throughout childhood and 
adolescence. Similarly, no single gene has been 
found to be responsible for any specific mental 
disorder; rather, variations in multiple genes 
contribute to a disruption in healthy brain function 
that, under certain environmental conditions, 
results in a mental illness. Moreover, it is now 
recognized that socioeconomic factors affect 
individuals' vulnerability to mental illness and 
mental health problems. Certain demographic and 
economic groups are more likely than others to 
experience mental health problems and some 
mental disorders. Vulnerability alone may not be 
sufficient to cause a mental disorder; rather, the 
causes of most mental disorders lie in some 



103 



Mental Health: A Report of the Surgeon General 



combination of genetic and environmental factors, 
which may be biological or psychosocial. 

The fact that many, if not most, people have 
experienced mental health problems that mimic or 
even match some of the symptoms of a diagnosable 
mental disorder tends, ironically, to prompt many 
people to underestimate the painful, disabling 
nature of severe mental illness. In fact, 
schizophrenia, mood disorders such as major 
depression and bipolar illness, and anxiety often 
are devastating conditions. Yet relatively few 
mental illnesses have an unremitting course marked 
by the most acute manifestations of illness; rather, 
for reasons that are not yet understood, the 
symptoms associated with mental illness tend to 
wax and wane. These patterns pose special 
challenges to the implementation of treatment plans 
and the design of service systems that are optimally 
responsive to an individual's needs during every 
phase of illness. As this report concludes, 
enormous strides are being made in diagnosis, 
treatment, and service delivery, placing the 
productive and creative possibilities of adulthood 
within the reach of persons who are encumbered by 
mental disorders. 

Late adulthood is when changes in health status 
may become more noticeable and the ability to 
compensate for decrements may become limited. As 
the brain ages, a person's capacity for certain 
mental tasks tends to diminish, even as changes in 
other mental activities prove to be positive and 
rewarding. Well into late life, the ability to solve 
novel problems can be enhanced through training in 
cognitive skills and problem-solving strategies. 

The promise of research on mental health 
promotion notwithstanding, a substantial minority 
of older people are disabled, often severely, by 
mental disorders including Alzheimer's disease, 
major depression, substance abuse, anxiety, and 
other conditions. In the United States today, the 
highest rate of suicide — an all-too-common 
consequence of unrecognized or inappropriately 
treated depression — is found in older males. This 
fact underscores the urgency of ensuring that health 



care provider training properly emphasizes skills 
required to differentiate accurately the causes of 
cognitive, emotional, and behavioral symptoms that 
may, in some instances, rise to the level of mental 
disorders, and in other instances be expressions of 
unmet general medical needs. 

As the life expectancy of Americans continues 
to extend, the sheer number — although not neces- 
sarily the proportion — of persons experiencing 
mental disorders of late life will expand, confront- 
ing our society with unprecedented challenges in 
organizing, financing, and delivering effective 
mental health services for this population. An 
essential part of the needed societal response will 
include recognizing and devising innovative ways 
of supporting the increasingly more prominent role 
that families are assuming in caring for older, 
mentally impaired and mentally ill family members. 

References 

Acosta, F. X., Yamamoto, J., & Evans, L. A. (1982). 

Effective psychotherapy for low-income and 

minority patients. New York: Plenum Press. 
Ahr, P. R., & Holcomb, W. R. (1985). State mental 

health directors' priorities for mental health care. 

Hospital and Community Psychiatry, 36, 39-45. 
American Psychiatric Association. (1952). Diagnostic 

and statistical manual of mental disorders (1st ed.). 

Washington, DC: Author. 
American Psychiatric Association. (1968). Diagnostic 

and statistical manual of mental disorders (2nd 

ed.). Washington, DC: Author. 
American Psychiatric Association. (1980). Diagnostic 

and statistical manual of mental disorders (3rd ed.). 

Washington, DC: Author. 
American Psychiatric Association. (1987). Diagnostic 

and statistical manual of mental disorders (3rd 

ed.-rev.). Washington, DC: Author. 
American Psychiatric Association. (1994). Diagnostic 

and statistical manual of mental disorders (4th ed.). 

Washington, DC: Author. 
Andreasen, N. C. (1997). Linking mind and brain in the 

study of mental illnesses: A project for a scientific 

psychopathology. Science, 275, 1586-1593. 



104 



The Fundamentals of Mental Health and Mental Illness 



Andrews, G. (1995). Workforce deployment: 

Reconciling demands and resources. AM5/ra/z<3A7 and 

New Zealand Journal of Psychiatry, 29, 394-402. 
Anthony, W. A. (1993). Recovery from mental illness: 

The guiding vision of the mental health service 

system in the 1990s. Psychological Rehabilitation 

Journal, 16, 1 1-24. 
Bacote, J. C. (1994). Transcultural psychiatric nursing: 

Diagnostic and treatment issues. Journal of 

Psychosocial Nursing, 32, 42-46. 
Bailey, C. H., & Kandel, E. R. (1993). Structural 

changes accompanying memory storage. Annual 

Review of Physiology, 55, 397-426. 
Bandura, A. (1969). Principles of behavior 

modification. New York: Holt, Rinehart & Winston. 
Bandura, A. (1977). Social learning theory. Englewood 

Cliffs, NJ: Prentice-Hall. 
Barondes, S. {1993). Molecules and mental illness. New 

York: Scientific American Library. 
Baum, A., & Posluszny, D. M. (1999). Health 

psychology: Mapping biobehavioral contributions to 

health and illness. Annual Review of Psychology, 

50, 137-163. 
Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. 

(1979). Cognitive therapy of depression. New York: 

Guilford Press. 
Beers, C. (1908). A mind that found itself: An 

autobiography. New York: Longmans Green. 
Beeson, P. G., Britain, C., Howell, M. L., Kirwan, D., & 

Sawyer, D. A. (1998). Rural mental health at the 

millennium. In Mandersheid, R. W., & Henderson, 

M. J. (Eds.), Mental Health United States, 1998 

(DHHS Publication No. (SMA)99-3285, pp. 82-98). 

Washington, DC: U.S. Government Printing Office. 
Belle, D. (1990). Poverty and women's mental health. 

American Psychologist, 45, 385-389. 
Berrento-Clement, J. R., Schweinhart, L. J., Barnett, W. 

S., Epstein, A. S., & Weikart, D. P. (1984). 

Changed lives: The effects of the Perry Preschool 

Program on youths through age 19. (High/Scope 

Educational Research Foundation, Monograph 8). 

Ypsilanti, ML High/Scope Press. 



Bird, D., Lambert, D., Hartley, D., Beeson, P., & 
Coburn, A. (1995). Integrating primary care and 
mental health services in rural America: A policy 
review and conceptual framework. Portland, ME: 
University of Southern Maine, Edmund Muskie 
Institute of Public Affairs, Maine Rural Health 
Research Center. 

Bird, D., Lambert, D., Hartley, D., Beeson, P., & 
Coburn, A. (1998). Rural models for integrating 
primary care and mental health services. 
Administration and Policy in Mental Health, 25, 
287-308. 

Bowlby, J. (1951). Maternal care and mental health. 
Geneva: World Health Organization. 

Breger, L. (1974). From instinct to identity: The 
development of personality. Englewood Cliffs, NJ: 
Prentice-Hall. 

Brenner, C. (1978). An elementary textbook of 
psychoanalysis (2nd ed.). New York: International 
Universities Press. 

Breslau, N., Kessler, R. C, Chilcoat, H. D., Schultz, L. 
R., Davis, G. C, & Andreski, P. (1998). Trauma 
and posttraumatic stress disorder in the community: 
The 1996 Detroit Area Survey of Trauma. Archives 
of General Psychiatry, 55, 626-632. 

Britain, C. S. (1996). Making the connection in rural 
mental health. Behavioral Healthcare Tomorrow, 5, 
67-69. 

Brody, T. M. (1994). Absorption, distribution, 
metabolism, and elimination. In T. M. Brody, J. 
Earner, K. Minneman, & H. Neu (Eds.), Human 
pharmacology: Molecular to clinical (2nd ed., pp. 
49-61). St. Louis: Mosby-Year Book. 

Broman, C. L. (1996). Coping with personal problems. 
In H. W. Neighbors & J. S. Jackson (Eds.), Mental 
health in black America (pp. 117-129). Thousand 
Oaks, CA: Sage. 

Cabaj, R. P., & Stein, T. S. (1996). Textbook of 
homosexuality and mental health. Washington, DC: 
American Psychiatric Press. 

Campbell, J. (1993). The Weil-Being Project: Mental 
health clients speak for themselves. Paper presented 
at the annual conference of Mental Health Services 
Research and Evaluation, Arlington, VA. 

Campbell, J. (1997). How consumers/survivors are 
evaluating the quality of psychiatric care. 
Evaluation Review, 21, 357-363. 



105 



Mental Health: A Report of the Surgeon General 



Campbell, J., Ralph, R., & Glover, R. (1993). From lab 
rat to researcher: The history, models, and policy 
implications of consumer/survivor involvement in 
research. Proceedings: Fourth annual national 
conference on state mental health agency services 
research and program evaluation (pp. 138-157). 
Alexandria, VA: The National Association of State 
Mental Health Program Directors. 

Campbell, J., & Schraiber, R. (1989). The Well-Being 
Project: Mental health clients speak for themselves. 
Sacramento, CA: California Department of Mental 
Health. 

Canino, G. J., Bird, H. R., Shrout, P. E., Rubio-Stipec, 
M., Bravo, M., Martinez, R., Sesman, M., & 
Guevara, L. M. (1987). The prevalence of specific 
psychiatric disorders in Puerto Rico. Archives of 
General Psychiatry, 44, 727-735. 

Center for Mental Health Services. (1998). Cultural 
competence standards in managed care mental 
health services for four underserved/ 
underrepresented racial/ethnic groups. Rockville, 
MD: Author. 

Centers for Disease Control and Prevention. (1991). 
Strategic plan for the elimination of childhood lead 
poisoning. Atlanta, GA: Author. 

Chamberlin, J. (1978). On our own: Patient-controlled 
alternatives to the mental health system. New York: 
McGraw-Hill. 

Chamberlin, J. (1990). The ex-patient's movement: 
Where we've been and where we're going. Journal 
of Mind and Behavior, 11, 323-336. 

Chamberlin, J. (1995). Rehabilitating ourselves: The 
psychiatric survivor movement. International 
Journal of Mental Health, 24, 39-46. 

Chamberlin, J. (1997). Confessions of a non-compliant 
patient. National Empowerment Center Newsletter. 
Lawrence, MA: National Empowerment Center. 

Chamberlin, J., & Rogers, J. A. (1990). Planning a 
community-based mental health system. Perspective 
of service recipients. American Psychologist, 45, 
1241-1244. 

Chambless, D. L., Baker, M. J., Baucom, D. H., Beutler, 
L. E., Calhoun, K. S., Crits-Christoph, P., Daiuto, 
A., Sanderson, W. C, Shoham, V., Stickle, T., 
Williams, D. A., & Woody, S. R. (1998). Update on 
empirically validated therapies H. Clinical 
Psychologist, 51 , 3-16. 



Chambless, D. L., Sanderson, W. C, Shohman, V., 
Bennett, J. S., Pope, K. S., Crits-Cristoph, P., 
Baker, M., Johnson, B., Woody, S. R., Sue, S., 
Beutler, L., Williams, D. A., & McMurry, S. (1996). 
An update on empirically validated therapies. 
Clinical Psychologist, 49, 5-18. 

Cheung, F. K., & Snowden, L. R. (1990). Community 
mental health and ethnic minority populations. 
Community Mental Health Journal, 26, 277-291. 

Ciarlo, J. A. (1998). Estimating and monitoring need for 
mental health services in rural frontier areas. Rural 
Community Mental Health, 24, 17-18. 

Clarke, G. N., Hawkins, W., Murphy, M., Sheeber, L. 
B., Lewinsohn, P. M., & Seeley, J. R. (1995). 
Targeted prevention of unipolar depressive disorder 
in an at-risk sample of high school adolescents: A 
randomized trial of a group cognitive intervention. 
Journal of the American Academy of Child and 
Adolescent Psychiatry, 34, 312-321. 

Cohen, S., & Herbert, T. B. (1996). Health psychology: 
Psychological factors and physical disease from the 
perspective of human psychoneuroimmunology. 
Annual Review of Psychology, 47, 1 13-142. 

Coie, J., & Krehbiel, G. (1984). Effects of academic 
tutoring on the social status of low-achieving, 
socially rejected children. Child Development, 55, 
1465-1478. 

Comas Diaz, L. (1989). Culturally relevant issues and 
treatment implications for Hispanics. In D. Koslow 
& E. Salett (Eds.), Crossing cultures in mental 
health (pp. 31-48). Washington, DC: SIETAR 
International. 

Commission on Chronic Illness. (1957). Chronic illness 
in the United States (Vol. 1). Cambridge, MA: 
Harvard University Press. 

Conwell, Y. (1996). Diagnosis and treatment of 
depression in late life. Washington, DC: American 
Psychiatric Press. 

Cook, J. A., & Jonikas, J. A. (1996). Outcomes of 
psychiatric rehabilitation service delivery. New 
Directions in Mental Health Services, 71, 33-47. 

Cook, K., & Timberlake, E. M. (1989). Cross-cultural 
counseling with Vietnamese refugees. In D. Koslow 
& E. Salett (Eds.), Crossing cultures in mental 
health (pp. 84-100). Washington, DC: SIETAR 
International. 



106 



The Fundamentals of Mental Health and Mental Illness 



Cooper, C. R., & Denner, J. (1998). Theories linking 

culture and psychopathology: Universal and 

community-specific processes. Annual Review of 

Psychology, 49, 559-584. 
Cooper, J. R., Bloom, F. E., & Roth, R. H. (1996). The 

biochemical basis of neuropharmacology. New 

York: Oxford University Press. 
Cross, T., Bazron, B., Dennis, K., & Isaacs, M. (1989). 

Towards a culturally competent system of care: A 

monograph on effective services for minority 

children who are severely emotionally disturbed. 

Washington, DC: Georgetown University Child 

Development Center. 
Danbom, D. (1995). Born in the country: A history of 

rural America. Baltimore: Johns Hopkins 

University Press. 
Davidson, L., & Strauss, J. S. (1992). Sense of self in 

recovery from severe mental illness. British Journal 

of Medical Psychology, 65, 131-145. 
Deegan, P. E. (1988). Recovery: The lived experience of 

rehabilitation. Psychiatric Rehabilitation Journal, 

11, 11-19. 
Deegan, P. E. (1997). Recovery and empowerment for 

people with psychiatric disabilities. Journal of 

Social Work and Health Care, 25, 1 1-24. 
del Pinal, J., & Singer, A. (1997). Generations of 

diversity: Latinos in the United States. Population 

Bulletin, 52, 1-44. 
Dixon, L. B., Lehman, A. P., & Levine, J. (1995). 

Conventional antipsychotic medications for 

^chizo-phrenidi. Schizophrenia Bulletin, 21,561-511 . 
Dohrenwend, B. P., Levav, I., Schwartz, S., Naveh, G., 

Link, B. G., Skodol, A. E., & Stueve, A. (1992). 

Socioeconomic status and psychiatric disorders: The 

causation-selection issue. Science, 255, 946-952. 
Duran, D. (1995). Impact of depression, psychological 

factors, cultural determinants and patient/care 

provider relationship on somatic complaints of the 

distressed Latina. Unpublished doctoral 

dissertation. University of Denver. 
DSM-I. See American Psychiatric Association (1952). 
DSM-IL See American Psychiatric Association (1968). 
DSM-IIL See American Psychiatric Association (1980). 
DSM-III-R. See American Psychiatric Association 

(1987). 
DSM-IV. See American Psychiatric Association (1994). 
Dyer, J. (1997). Harvest of rage: Why Oklahoma City is 

only the beginning. Boulder, CO: Westview Press. 



Emerick, R. (1990). Self-help groups for former 
patients: Relations with mental health professionals. 
Hospital and Community Psychiatry, 41 , 401-407. 

Engel, G. L. (1977). The need for a new medical model: 
A challenge for biomedicine. Science, 196, 
129-136. 

Epstein, L. G., & Gendelman, H. E. (1993). Human 
immunodeficiency virus type 1 infection of the 
nervous system: Pathogenetic mechanisms. Annals 
of Neurology, 33, 429-436. 

Erikson, E. (1950). Childhood and society. New York: 
Norton. 

Farragher, B. (1998). Psychiatric morbidity following 
the diagnosis and treatment of early breast cancer. 
Irish Journal of Medical Science, 167, 166-169. 

Federation of Families for Children's Mental Health. 
(1999). Federation of Families for Children's 
Mental Health home page. [On-line]. Available: 
http://www.ffcmh.org 

Feldman, R. S. {\991). Development across the lifespan. 
Upper Saddle River, NJ: Prentice-Hall. 

Fischbach, G. D. (1992). Mind and brain. Scientific 
American, 267, 48-57. 

Frasure-Smith, N.,Lesperance,F., &Talajic, M. (1993). 
Depression following myocardial infarction. Impact 
on 6-month survival. Journal of the American 
Medical Association, 270, 1819-1825. 

Frasure-Smith, N., Lesperance, F., & Talajic, M. (1995). 
Depression and 18-month prognosis after 
myocardial infarction. Circulation, 91, 999-1005. 

Frese, F. J. (1998). Advocacy, recovery, and the 
challenges of consumerism for schizophrenia. 
Psychiatric Clinics of North America, 21, 233-249. 

Frese, F. J., & Davis, W. W. (1997). The consumer- 
survivor movement, recovery, and consumer 
professionals. Professional Psychology: Research 
and Practice, 28, 243-245. 

Friedman, L. M., Furberg, C. D., & DeMets, D. L. 
(1996a). Fundamentals of clinical trials (3rd ed.). 
St. Louis: Mosby. 

Friedman, R. M., Katz-Levey, J. W., Manderschied, R. 
W., & Sondheimer, D. L. (1996b). Prevalence of 
serious emotional disturbance in children and 
adolescents. In R. W. Manderscheid & M. A. 
Sonnenschein (Eds.), Mental health. United States, 
1996 (pp. 71-88). Rockville, MD: Center for 
Mental Health Services. 



107 



Mental Health: A Report of the Surgeon General 



Friesen, B. J., & Stephens B. (1998). Expanding family 
roles in the system of care: Research and practice. 
In M. R. Epstein, K. Kutash, & A. J. Duchnowski 
(Eds.), Outcomes for children and youth with 
behavioral and emotional disorders and their 
families: Programs and evaluation, best practices 
(pp. 231-259). Austin, TX: Pro-Ed. 

Fukuyama, F. (1995). Trust. New York: Free Press. 

Furlong-Norman, K. (1988). Community Support 
Network News, 5, 2. 

Gallo, J. J., Marino, S., Ford, D., & Anthony, J. C. 
(1995). Filters on the pathway to mental health care, 
II. Sociodemographic factors. Psychological 
Medicine, 25, 1149-1160. 

Garcia, M., & Rodriguez, P. F. (1989). Psychological 
effects of political repression in Argentina and El 
Salvador. In D. Koslow & E. Salett (Eds.), Crossing 
cultures in mental health (pp. 64-83). Washington, 
DC: SIETAR International. 

Garmezy, N. (1983). Stressors of childhood. In N. 
Garmezy & M. Rutter (Eds.), Stress, coping, and 
development in children (pp. 43-84). New York: 
McGraw-Hill. 

Garvey, M. A., Giedd, J., & Swedo, S. E. (1998). 
PANDAS: The search for environmental triggers of 
pediatric neuropsychiatric disorders. Lessons from 
rheumatic fever. Journal of Child Neurology, 13, 
413-423. 

Gazzaniga, M. S., Ivry, R. B., & Mangun, G. R. (1998). 
Cognitive neuroscience: The biology of the mind. 
New York: W. W. Norton. 

Geller, J. L., Brown, J. M., Fisher, W. H., Grudzinskas, 
A. J., Jr., & Manning, T. D. (1998). A national 
survey of "consumer empowerment" at the state 
level. Psychiatric Services, 49, 498-503. 

General Accounting Office. (1977). Returning the 
mentally disabled to the community: Government 
needs to do more. Washington, DC: Author. 

Goldman, H. H. (1998). Deinstitutionalization and 
community care: Social welfare policy as mental 
health policy. Harvard Review of Psychiatry, 6, 
219-222. 

Goldman, H. H., & Morrissey, J. P. (1985). The 
alchemy of mental health policy: Homelessness and 
the fourth cycle of reform. American Journal of 
Public Health, 75, 727-731. 

Gordon, M. F. (1964). Assimilation in American life. 
New York: Oxford University Press. 



Granger, D. A. (1994). Recovery from mental illness: A 
first person perspective of an emerging paradigm. In 
Ohio Department of Mental Health, Recovery: The 
new force in mental health (pp. 1-13). Columbus, 
OH: Author. 

Grant, I., Atkinson, J. H., Hesselink, J. R., Kennedy, C. 
J., Richman, D. D., Spector, S. A., & McCutchan, J. 
A. (1987). Evidence for early central nervous 
system involvement in the acquired 
immunodeficiency syndrome (AIDS) and other 
human immunodeficiency virus (HIV) infections. 
Studies with neuropsychologic testing and magnetic 
resonance imaging. Annals of Internal Medicine, 
107, 828-836. 

Grob, G. N. (1983). Mental illness and American 
society, 1875-1940. Princeton, NJ: Princeton 
University Press. 

Grob, G. N. (1991). From asylum to community. Mental 
health policy in modern America. Princeton, NJ: 
Princeton University Press. 

Grob, G. N. (1994). The mad among us: A history of the 
care of America 's mentally ill. New York: Free 
Press. 

Grover, P.L. (1998). Preventing substance abuse among 
children and adolescents: Family-centered ap- 
proaches: Prevention enhancement protocols system 
reference guide. Rockville, MD: Center for 
Substance Abuse Prevention. 

Hannan, R. W. (1998). Intervention in the coal fields: 
Mental health outreach. Rural Community Mental 
Health, 24, 1-3. 

Harding, C, Strauss, J. S., & Zubin, J. (1992). Chroni- 
city in schizophrenia: Revisited. British Journal of 
Psychiatry, 161, 27-37. 

Harrow, M., Sands, J. R., Silverstein, M. L., & 
Goldberg, J. F. (1997). Course and outcome for 
schizophrenia versus other psychotic patients: A 
longitudinal study. Schizophrenia Bulletin, 23, 
287-303. 

Hatchett, S. J., & Jackson, J. S. (1993). African 
American extended kin systems: An assessment. In 
H. P. McAdoo (Ed.), Family ethnicity: Strength in 
diversity (pp. 90-108). Newbury Park, CA: Sage. 

Health Care Financing Administration. (1991). 
International classification of diseases (9th 
revision, clinical modification, ICD-9-CM). 
Washington, DC: Author. 



108 



The Fundamentals of Mental Health and Mental Illness 



Hernandez, M., Isaacs, M. R., Nesman, T., & Burns, D. 
(1998). Perspectives on culturally competent 
systems of care. In M. Hernandez & M. R. Isaacs 
(Eds.), Promoting cultural competence in children 's 
mental health services (pp. 1-25). Baltimore: Paul 
H. Brookes. 

Herring, R. D. (1994). Native American Indian identity: 
A people of many peoples. In E. Salett & D. Koslow 
(Eds.), Race, ethnicity, and self: Identity in 
multicultural perspective (pp. 170-197). 
Washington, DC: National Multicultural Institute. 

Holzer, C, Shea, B., Swanson, J., Leaf, P., Myers, J., 
George, L., Weissman, M., & Bednarski, P. (1986). 
The increased risk for specific psychiatric disorders 
among persons of low socioeconomic status. 
American Journal of Social Psychiatry, 6, 259-27 1 . 

Horowitz, M. J. (1988). Introduction to 
psychodynamics: A new synthesis. New York: Basic 
Books. 

Horwitz, A. V. (1987). Help-seeking processes and 
mental health services. New Directions for Mental 
Health Services, 36, 33-45. 

Hough, R. L., Landsverk, J. A., Karno, M., Burnam, M. 
A., Timbers, D. M., Escobar, J. I., & Regier, D. A. 
(1987). Utilization of health and mental health 
services by Los Angeles Mexican Americans and 
non-Hispanic whites. Archives of General 
Psychiatry, 44, 702-709. 

Hoyt, D. R., Conger, R. D., Valde, J. G., & Weihs, K. 
(1997). Psychological distress and help seeking in 
rural America. American Journal of Community 
Psychology, 25, 449-470. 

Hoyt, D., O'Donnell D., & Mack, K. Y. (1995). 
Psychological distress and size of place: The 
epidemiology of rural economic stress. Rural 
Sociology, 60, 707-720. 

Hu, T. W., Snowden, L. R., Jerrell, J. M., & Nguyen, T. 
D. (1991). Ethnic populations in public mental 
health: Services choice and level of use. American 
Journal of Public Health, 81, 1429-1434. 

Hubel, D., & Wiesel T. (1970). The period of 
susceptibility to the physiological effects of 
unilateral eye closure in kittens. Journal of 
Physiology, 206, 419-436. 



Hunt, D. (1984). Issuesin working with Southeast Asian 
refugees. In D. Koslow & E. Salett (Eds.), Crossing 
cultures in mental health (pp. 49-63). Washington, 
DC: SIETAR International. 

Indian Health Service. (1997). Trends in Indian health 
1997. [On-line]. Available: http://www.ihs.gOv// 
publicinfo/publications/trends97/trends97.asp 

Inhelder, B., & Piaget, J. (1958). The growth of logical 
thinking from childhood to adolescence: An essay 
on the construction of formal operational 
structures. New York: Basic Books. 

Institute of Medicine. (1990). Broadening the base of 
treatment for alcohol problems: Report of a study 
by a committee of the Institute of Medicine, Division 
of Mental Health and Behavioral Medicine. 
Washington, DC: National Academy Press. 

Institute of Medicine. (1994a). Reducing risks for 
mental disorders: Frontiers for preventive 
intervention research. Washington, DC: National 
Academy Press. 

Institute of Medicine. (1994b). Adverse events 
associated with childhood vaccines: Evidence 
bearing on causality. Washington, DC: National 
Academy Press. 

Institute of Medicine & Committee for the Study of the 
Future of Public Health. (1988). The future of 
public health. Washington, DC: National Academy 
Press. 

Interagency Council on the Homeless. (1991). Reaching 
out: A guide for service providers. Rockville, MD: 
The National Resource Center on Homelessness and 
Mental Health. 

Jenkins, E. J., & Bell, C. C. (1997). Exposure and 
response to community violence among children and 
adolescents. In J. Osofsky (Ed.), Children in a 
violent society (pp. 9-31). New York: Guilford 
Press. 

Jimenez, A. L., Alegria, M., Pena, M., & Vera, M. 
(1997). Mental health utilization in depression. 
Women & Health, 25(2), 1-21. 

Kalichman, S. C, Carey, P. M., & Johnson, B. T. (in 
press). Prevention of sexually transmitted HIV 
infection. A meta-analytic review of the behavioral 
outcome literature. Annals of Behavioral Medicine. 

Kanas, N. (in press). Group psychotherapy. In H. H. 
Goldman (Ed.), Review of general psychiatry (5th 
ed.). Norwalk, CT: Appleton and Lange. 



109 



Mental Health: A Report of the Surgeon General 



Kandel, E. R. (1998). A new intellectual framework for 
psychiatry. American Journal of Psychiatry, 155, 
457-469. 

Kandel, E. R., Schwartz, J. H., & Jessell, T. M. (1995). 
Essentials of neural sciences and behavior. 
Stanford, CT: Appleton and Lange. 

Kaplan, G. A., Roberts, R. E., Camacho, T. C, & 
Coyne, J. C. (1987). Psychosocial predictors of 
depression. Prospective evidence from the human 
population laboratory studies. American Journal of 
Epidemiology, 125, 206-220. 

Kaplan, H. I., & Saddock, B. J. (1998). Synopsis of 
psychiatry (8th ed.). Baltimore: Williams and 
Wilkins. 

Karno, M., Jenkins, J. H., de la Selva, A., Santana, P., 
Telles, C, Lopez, S., & Mintz, J. (1987). Expressed 
emotion and schizophrenic outcome among 
Mexican-American families. Journal of Nervous 
and Mental Disease, 175, 143-151. 

Kazdin, A. E. (1996). Cognitive behavioral approaches. 
In M. Lewis (Ed.), Child and adolescent psychiatry: 
A comprehensive textbook (2nd ed., pp. 115-126). 
Baltimore: Williams and Wilkins. 

Kazdin, A. E. (1997). Behavior modification. In J. M. 
Weiner (Ed.), Textbook of child and adolescent 
psychiatry (2nd ed., pp. 82 1-842). Washington, DC: 
American Academy of Child and Adolescent 
Psychiatry. 

Kellam, D. G., & Rebok, G. W. (1992). Building 
developmental and etiological theory through 
epidemiologically-based preventive intervention 
trials. In J. McCord & R. E. Tremblay (Eds.), 
Preventing antisocial behavior: Interventions from 
birth through adolescence (pp. 162-195). New 
York: Guilford Press. 

Kessler, R. C, Berglund, P. A., Zhao, S., Leaf, P. J., 
Kouzis, A. C, Bruce, M. L., Friedman, R. M., 
Grossier, R. C, Kennedy, C, Narrow, W. E., 
Kuehnel, T. G., Laska, E. M., Manderscheid, R. W., 
Rosenheck, R. A., Santoni, T. W., & Schneier, M. 
(1996). The 12-month prevalence and correlates of 
serious mental illness, In Manderscheid, R. W., & 
Sonnenschein, M. A. (Eds.), Mental health. United 
States, 1996 (DHHS Publication No. (SMA) 96- 
3098, pp. 59-70). Washington, DC: U.S. 
Government Printing Office. 



Kessler, R. C, McGonagle, K. A., Zhao, S., Nelson, C. 
B., Hughes, M., Eshleman, S., Wittchen, H. U., & 
Kendler, K. S. (1994). Lifetime and 12-month 
prevalence of DSM-III-R psychiatric disorders in 
the United States. Results from the National 
Comorbidity Survey. Archives of General 
Psychiatry , 51, 8-19. 

Kimmel, W. A. (1992). Rural mental health policy 
issues for research: A pilot exploration. Rockville, 
MD: National Institute of Mental Health, Office of 
Rural Mental Health Research. 

Kinzie, J. D., Leung, P. K., Boehnlein, J., Matsunaga, 
D., Johnson, R., Manson, S., Shore, J. H., Heinz, J., 
& Williams, M. (1992). Psychiatric epidemiology of 
an Indian village. A 19-year replication study. 
Journal of Nervous and Mental Disease, 180, 
33-39. 

Klerman, G. L., Weissman, M. M., Rousaville, B. J., & 
Sherron, E. S. (1984). Interpersonal psychotherapy 
of depression. New York: Basic Books. 

Knitzer, J. (1982). Unclaimed children: The failure of 
public responsibility to children and adolescents in 
need of mental health services. Washington, DC: 
Children's Defense Fund. 

Kosslyn, S. M., & Shin, L. M. (1992). The status of 
cognitive neuroscience. Current Opinions in 
Neurobiology, 2, 146-149. 

La Mendola, W. (1997). Telemental health services in 
t/.5./ronn>rarea5 (Frontier Mental Health Services 
Resource Network, Letter to the Field, No. 3). [On- 
line]. Available: http://www.du.edu/frontier-mh/ 
letter3.html. 

Lamb, H. R. ( 1 994). A century and a half of psychiatric 
rehabilitation in the United States. Hospital and 
Community Psychiatry, 45, 1015-1020. 

Larson, D. B., Hohmann, A., Kessler, L. G., Meador, K. 
G., Boyd, J. H., & McSherry, E. (1988). The couch 
and the cloth: The need for linkage. Hospital and 
Community Psychiatry, 39, 1064-1069. 

Lawson, W. B., Hepler, N., Holladay, J., & Cuffel, B. 
(1994). Race as a factor in inpatient and outpatient 
admissions and diagnosis. Hospital and Community 
Psychiatry, 45, 72-74. 

Lebowitz, B. D., & Rudorfer, M. V. (1998). Treatment 
research at the millenium: From efficacy to effect- 
iveness. Journal of Clinical Psychopharmacology, 
18, 1. 



110 



The Fundamentals of Mental Health and Mental Illness 



Lee, S. M. (1998). Asian Americans: Diverse and 
growing. Population Bulletin, 53, 1-39. 

Leete, E. (1989). How I perceive and manage my illness. 
Schizophrenia Bulletin, 8, 605-609. 

Lefley, H. P. (1996). Impact of consumer and family 
advocacy movement on mental health services. In B. 
L. Levin & J. Petrila (Eds.), Mental health services: 
A public health perspective {^^. 81-96). New York: 
Oxford University Press. 

Lefley, H. (1997). Mandatory treatment from the 
family's perspective. New Directions in Mental 
Health Services, 75, 7-16. 

Lehman, A. F., & Steinwachs, D. M. (1998). Translating 
research into practice: The Schizophrenia Patient 
Outcomes Research Team (PORT) treatment 
XQComm&nddiiions. Schizophrenia Bulletin, 24, 1-10. 

Leong, F. T., & Lau, A. S. (1998). Barriers to providing 
ejfective mental health services to Asian Americans. 
Manuscript submitted for publication. 

Levine, J. D., Gordon, N. C, & Fields, H. L. (1978). 
The mechanism of placebo analgesia. Lancet, 2, 
654-657. 

Lin, K. M., Anderson, D., & Poland, R. E. (1997). 
Ethnic and cultural considerations in 
psychopharmacotherapy. In D. Dunner (Ed.), 
Current psychiatric therapy II (pp. 75-81). 
Philadelphia: W. B. Saunders. 

Lin, K., Inui, T. S., Kleinman, A. M., & Womack, W. 
M. (1982). Sociocultural determinants of the help- 
seeking behavior of patients with mental illness. 
Journal of Nervous and Mental Disease, 170, 
78-85. 

Lombroso, P., Pauls, D., & Leckman, J. (1994). Genetic 
mechanisms in childhood psychiatric disorders. 
Journal of the American Academy of Child and 
Adolescent Psychiatry, 33, 921-938. 

Long, A. E. (1994). Reflections on recovery. In Ohio 
Department of Mental Health, Recovery: The new 
force in mental health (pp. 1-16). Columbus, OH: 
Author. 

Long, L., & Van Tosh, L. (1988). Program descriptions 
of consumer-run programs for homeless people with 
mental illness. Rockville, MD: National Institute of 
Mental Health. 



Lopez, S. R. (in press). Cultural competence in 
psychotherapy: A guide for clinicians and their 
supervisors. In C. E. Watkins, Jr. (Ed.), Handbook 
of psychotherapy supervision. New York: Wiley. 

Lopez, S., Nelson, K., Polo, A., Jenkins, J., Karno, M., 
& Snider, K. S. (in press). Family warmth and 
course of schizophrenia in Mexican and Anglo 
Americans. Journal of Abnormal Psychology. 

Lu, F. G., Lim, R. F., & Mezzich, J. E. (1995). Issues in 
the assessment and diagnosis of culturally diverse 
individuals. In J. Oldham & M. Riba (Eds.), Review 
of Psychiatry (Vol. 14, pp. 477-510). Washington, 
DC: American Psychiatric Press. 

Manson, S. M. (1998). Mental health services for 
American Indians: Need, use, and barriers to 
effective care. Manuscript submitted for 
publication. 

McArthur, J. C, Hoover, D. R., Bacellar, H., Miller, E. 
N., Cohen, B. A., Becker, J. T., Graham, N. M., 
McArthur, J. H., Seines, O. A., Jacobson, L. P., 
Visscher, B. R., Concha, M., & Saah, A. (1993). 
Dementia in AIDS patients: Incidence and risk 
factors. Multicenter AIDS Cohort Study. 
Neurology, 43, 2245-2252. 

McEwen, B. S. (1998). Protective and damaging effects 
of stress mediators. New England Journal of 
Medicine, 338, 171-179. 

McEwen, B. S., & Magarinos, A. M. (1997). Stress 
effects on morphology and function of the 
hippocampus. Annals of the New York Academy of 
Sciences, 827,271-284. 

McGauhey, P., Starfield, B., Alexander, C, & 
Ensminger, M. E. (1991). Social environment and 
vulnerability of low birth weight children: A social- 
epidemiological perspective. Pediatrics, 88, 
943-953. 

McLeod, J. D.. & Kessler, R. C. (1990). Socioeconomic 
status differences in vulnerability to undesirable life 
events. Journal of Health and Social Behavior, 31, 
162-172. 

Meadows, M. (1997). Mental health and minorities: 
Cultural considerations in treating Asians. Closing 
the Gap, 1-2. 

Melaville, B., & Asayesh, G. (1993). Together we can: 
A guide for crafting a profamily system of education 
and human services. Washington, DC: U.S. 
Department of Education. 



Ill 



Mental Health: A Report of the Surgeon General 



Mezzich, J. E., Kleinman, A., Fabrega, H., & Parron, D. 
L. (Eds.)- (1996). Culture and psychiatric 
diagnosis: A DSM-IV perspective. Washington, DC: 
American Psychiatric Press. 

Milburn, N. G., & Bowman, P. J. (1991). Neighborhood 
life. In J. S. Jackson (Ed.), Life in black America 
(pp. 31-45). Newbury Park, CA: Sage. 

Minneman, K. (1994). Pharmacological organization of 
the central nervous system. In T. M. Brody, J. 
Earner, K. Minneman, & H. Neu (Eds.), Human 
pharmacology: Molecular to clinical. St. Louis: 
Mosby-Year Book. 

Miranda, J., & Green, B. L. (1999). The need for mental 
health services research focusing on poor young 
women. Journal of Mental Health Policy and 
Economics, 2, 73-89. 

Mohatt, D., & Kirwan, D. (1995). Meeting the 
challenge: Model programs in rural mental health. 
Rockville, MD: Office of Rural Health Policy. 

Mollica, R. F. (1989). Developing effective mental 
health policies and services for traumatized refugee 
patients. In D. Koslow & E. Salett (Eds.), Crossing 
cultures in mental health (pp. 101-115). 
Washington, DC: SIETAR International. 

Morrissey, J. P., & Goldman, H. H. (1984). Cycles of 
reform in the care of the chronically mentally ill. 
Hospital and Community Psychiatry, 35, 785-793. 

Mowbray, C, Moxley, D., Thrasher, S., Bybee, D., 
McCrohan, N., Harris, S., & Clover, G. (1996). 
Consumers as community support providers: Issues 
created by role innovation. Community Mental 
Health Journal, 32, 47-67. 

Munoz, R. F., Hollon, S. D., McGrath, E., Rehm, L. P., 
& VandenBos, G. R. (1994). On the AHCPR 
depression in primary care guidelines. Further 
considerations for practitioners. American 
Psychologist, 49, 42-61. 

Munoz, R. F., Ying, Y., Arman, R., Chan, F., & Gurza, 
R. ( 1987). The San Francisco depression prevention 
research project: A randomized trial with medical 
outpatients. In R. F. Munoz (Ed.), Depression 
prevention: Research directions (pp. 199-215). 
Washington, DC: Hemisphere Press. 



National Advisory Mental Health Council. (1993). 
Health care reform for Americans with severe 
mental illnesses: Report of the National Advisory 
Mental Health Council. American Journal of 
Psychiatry, 150, 1447-1465. 

National Alliance for the Mentally 111. (1999). State 
mental illness parity laws Arlington, VA: Author. 

National Association of State Mental Health Program 
Directors. (1993). Putting their money where their 
mouths are: SMHA support of consumer and family- 
run programs. Arlington, VA: Author. 

National Institute of Mental Health. (1998). Genetics 
and mental disorders: Report of the National 
Institute of Mental Health's Genetics Workgroup. 
Rockville, MD: Author. 

National Mental Health Association. (1987). Invisible 
Children Project. Final report and 
recommendations of the Invisible Children Project. 
Alexandria, VA: Author. 

National Mental Health Association. ( 1993). A guide for 
advocates to all systems failure. An examination of 
the results of neglecting the needs of children with 
serious emotional disturbance. Alexandria, VA: 
Author. 

National Resource Center on Homelessness and Mental 
Illness. (1989). Self-help programs for people who 
are homeless and mentally ill. Delmar, NY: Policy 
Research Associates. 

Navia, B. A., Jordan, B. D., & Price, R. W. (1986). The 
AIDS dementia complex: I. Clinical features. 
Annals of Neurology, 19, 517-524. 

Neighbors, H. W., Bashshur, R., Price, R., Donavedian, 
A., Selig, S., & Shannon, G. (1992). Ethnic minority 
health service delivery: A review of the literature. 
Research in Community and Mental Health, 7, 
55-71. 

Nelson, S. H., McCoy, G. F., Stetter, M., & 
Vanderwagen, W. C. (1992). An overview of mental 
health services for American Indians and Alaska 
Natives in the 1990s. Hospital and Community 
Psychiatry, 43,251-261. 

Nemeroff, C. B. (1998). Psychopharmacology of 
affective disorders in the 21st century. Biological 
Psychiatry, 44, 517-525. 

O'Hare, W. P. (1996). A new look at poverty in 
America. Population Bulletin, 51,1. 



112 



The Fundamentals of Mental Health and Mental Illness 



O'Hare, W. P., Pollard, K. M., Mann, T. L., & Kent, M. 
M. (1991). African-Americans in the 1990s. 
Population Bulletin, 46, 1-40. 

Olds, D. L., Henderson, C. R., Jr., Tatelbaum, R., & 
Chamberlin, R. (1986). Improving the delivery of 
prenatal care and outcomes of pregnancy: A 
randomized trial of nurse home visitation. 
Pediatrics, 77, 16-28. 

Olweus, D. (1991). Bullying/victim problems among 
school children: Basic facts and effects of an 
intervention program. In K. Rubin & D. Pepler 
(Eds.), Development and treatment of childhood 
aggression (pp. 41 1-448). Hillsdale, NJ: Lawrence 
Erlbaum Associates. 

Ortega, S. T., Johnson, D. R., Beeson, P. G., & Craft, B. 
(1994). The farm crisis and mental health: A 
longitudinal study of the 1980's. Rural Sociology, 
59,598-619. 

O'Sullivan, M. J., Peterson, P. D., Cox, G. B., & 
Kirkeby, J. (1989). Ethnic populations: Community 
mental health services ten years later. American 
Journal of Community Psychology, 17, 17-30. 

Padgett, D. K., Patrick, C, Burns, B. J., & Schlesinger, 
H. J. (1995). Use of mental health services by black 
and white elderly. In D. K. Padgett (Ed.), Handbook 
of ethnicity, aging, and mental health. Westport, 
CT: Greenwood Press. 

Pargament, K. I. (1997). The psychology of religion and 
coping: Theory, research, practice. New York: 
Guilford Press. 

Pasamanick, B. A. (1959). The epidemiology of mental 
disorder. Washington, DC: American Association 
for the Advancement of Science. 

Penninx, B. W., Guralnik, J. M., Pahor, M., Ferrucci, 
L., Cerhan, J. R., Wallace, R. B., & Havlik, R. J. 
( 1 998). Chronically depressed mood and cancer risk 
in older persons. Journal of the National Cancer 
Institute, 90, 1888-1893. 

Perry, P., Alexander, B., & Liskow, B. (1997). 
Psychotrophic drug handbook (7th ed.). 
Washington, DC: American Psychiatric Press. 

Pierce, C. M. (1992). Contemporary psychiatry: Racial 
perspectives on the past and future. In A. Kales, C. 
M. Pierce, & M. Greenblatt (Eds.), The mosaic of 
contemporary psychiatry in perspective (pp. 
99-109). New York: Springer-Verlag. 



Pirkle, J. L., Brody, D. J., Gunter, E. W., Kramer, R. A., 
Paschal, D. C, Flegal, K. M., & Matte, T. D. 
(1994). The decline in blood lead levels in the 
United States. The National Health and Nutrition 
Examination Surveys. Journal of the American 
Medical Association, 272, 284-291. 

Plomin, R. (1996). Beyond nature vs nurture. In L. L. 
Hall (Ed.), Genetics and mental illness: Evolving 
issues for research and society (pp. 29-50). New 
York: Plenum Press. 

Plomin, R., Owen, M. J., & McGuffin, P. (1994). The 
genetic basis of complex human behaviors. Science, 
264,1133-7139. 

Plomin, R., DeFries, J. C, McClearn, G. E., & Rutter, 
M. (1997). Behavioral genetics (3rd ed.). New 
York: W. H. Freeman. 

Porter, R. (1987). A social history of madness: Stories 
of the insane. London: Weidenfeld and Nicholson. 

Potter, W. Z., Scheinin, M., Golden, R. N., Rudorfer, 
M. v., Cowdry, R. W., Calil, H. M., Ross, R. J., & 
Linnoila, M. (1985). Selective antidepressants and 
cerebrospinal fluid. Lack of specificity on nor- 
epinephrine and serotonin metabolites. Archives of 
General Psychiatry, 42, 1171-1177. 

President's Commission on Mental Health. (1978). 
Report to the President from the President's Com- 
mission on Mental Health (4 Vols.). Washington, 
DC: Superintendent of Documents, U.S. Govern- 
ment Printing Office. 

Priest, R. (1991). Racism and prejudice as negative 
impacts on African American clients in therapy. 
Journal of Counseling and Development, 70, 
213-215. 

Primm, A. B., Lima, B. R., & Rowe, C. L. (1996). 
Cultural and ethnic sensitivity. In W. R. Breakey 
(Ed.), Integrated mental health services: Modern 
community psychiatry (pp. 146-159). New York: 
Oxford University Press. 

Rauch, K. D. (1997, December 9). Mental health care 
scarce in rural areas. The Washington Post Health, 
pp. 7-9. 

Regier, D. A., Narrow, W. E., Rupp, A., & Rae, D. S. 
(in press). The epidemiology of mental disorders 
treatment needs: Community estimates of "medical 
necessity." In G. Andrews & S. Henderson (Eds.), 
Unmet needs in mental health service delivery. 
Cambridge, England: Cambridge University Press. 



113 



Mental Health: A Report of the Surgeon General 



Regier, D. A., Farmer, M. E., Rae, D. S., Myers, J. K., 
Kramer, M., Robins, L. N., George, L. K., Karno, 
M., & Locke, B. Z. (1993a). One-month prevalence 
of mental disorders in the United States and 
sociodemographic characteristics: The Epidemiolog- 
ic Catchment Area study. Acta Psychiathca 
Scandinavica, 88, 35-47. 

Regier, D. A., Narrow, W. E., Rae, D. S., 
Manderscheid, R. W., Locke, B. Z., & Goodwin, F. 
K. (1993b). The de facto US mental and addictive 
disorders service system. Epidemiologic Catchment 
Area prospective 1-year prevalence rates of 
disorders and services. Archives of General 
Psychiatry, 50, 85-94. 

Resnick, H. S., Kilpatrick, D. G., Dansky, B. S., 
Saunders, B. E., & Best, C. L. (1993). Prevalence of 
civilian trauma and posttraumatic stress disorder in 
a representative national sample of women. Journal 
of Consulting and Clinical Psychology, 61, 
984-991. 

Rice, D. P., & Miller, L. S. (1996). The economic 
burden of schizophrenia: Conceptual and 
methodological issues, and cost estimates. In M. 
Moscarelli, A. Rupp, & N. Sartorious (Eds.), 
Handbook of mental health economics and health 
policy. Vol. 1: Schizophrenia (pp. 321-324). New 
York: John Wiley and Sons. 

Robins, L. N. (1970). Follow-up studies investigating 
childhood disorders. In E. H. Hare & J. K. Wayne 
(Eds.), Psychiatric epidemiology (pp. 29-68). 
London: Oxford University Press. 

Robins, L. N., & Regier, D. A. (1991). Psychiatric 
disorders in America: The Epidemiologic 
Catchment Area study. New York: Free Press. 

Rogers, C. (1961). On becoming a person. Boston: 
Houghton Mufflin. 

Rogers, E. S., Chamberlin, J., Ellison, M. L., & Crean, 
T. (1997). A consumer-constructed scale to measure 
empowerment among users of mental health 
^e.xvice,s. Psychiatric Services, 48, 1042-1047. 

Rogler, L. H., Malgady, R. G., Costantino, G., & 
Blumenthal, R. (1987). What do culturally sensitive 
mental health services mean? The case of Hispanics. 
American Psychologist, 42, 565-570. 

Rutter, M. (1979). Protective factors in children's 
responses to stress and disadvantage. Annals of the 
Academy of Medicine, Singapore, 8, 324-338. 



Sapolsky, R. M. (1996). Stress, glucocorticoids, and 
damage to the nervous system: The current state of 
confusion. Stress, 1, 1-19. 

Scheffler, R. M., & Miller, A. B. (1991). Differences in 
mental health service utilization among ethnic 
subpopulations. International Journal of Law and 
Psychiatry, 14, 363-376. 

Schlageter,C. (Ed.). (1990). OMH News II (l). Albany, 
NY: New York State Office of Mental Health. 

Schloss, P., & Williams, D. C. (1998). The serotonin 
transporter: A primary target for antidepressant 
drugs. Journal of Psychopharmacology, 12, 
115-121. 

Schweizer, E., & Rickels, K. (1997). Placebo response 
in generalized anxiety: Its effect on the outcome of 
clinical trials. Journal of Clinical Psychiatry, 
55(Suppl. 11), 30-38. 

Segal, S. P., Bola, J. R., & Watson, M. A. (1996). Race, 
quality of care, and antipsychotic prescribing 
practices in psychiatric emergency services. 
Psychiatric Services, 47, 282-286. 

Segal, S. P., Silverman, C, & Temkin, T. (1995). 
Measuring empowerment in client-run self-help 
agencies. Community Mental Health Journal, 31, 
215-227. 

Seligman, M. E. (1995). The effectiveness of 
psychotherapy. The Consumer Reports study. 
American Psychologist, 50, 965-974. 

Shaffer, D., Fisher, P., Dulcan, M. K., Davies, M., 
Piacentini, J., Schwab-Stone, M. E., Lahey, B. B., 
Bourdon, K., Jensen, P. S., Bird, H. R., Canino, G., 
& Regier, D. A. (1996). The NIMH Diagnostic 
Interview Schedule for Children Version 2.3 (DISC- 
2.3): Description, acceptability, prevalence rates, 
and performance in the MECA Study. Methods for 
the Epidemiology of Child and Adolescent Mental 
Disorders Study. Journal of the American Academy 
of Child and Adolescent Psychiatry, 35, 865-877. 

Shalev, A. Y. (1996). Stress vs. traumatic stress: From 
acute homeostatic reactions to chronic 
psychopathology. In B. A. Van der Kolk, A. C. 
MacFarlane, & L. Weisaeth (Eds.), Traumatic stress 
(pp. 77-101). New York: Guilford Press. 

Shatz, C. J. (1993). The developing brain. In Readings 
from Scientific American: Mind and brain (pp. 
15-26). New York: W. H. Freeman. 



114 



The Fundamentals of Mental Health and Mental Illness 



Short, P., Feinleib, S., & Cunningham, P. (1994). 

Expenditures and sources of payment for persons in 

nursing and personal care homes (AHCPR 

Publication No. 9400-0032). Rockville, MD: 

Agency for Health Care Policy and Research. 
Silverman, P. R. (1988). Widow to widow: A mutual 

help program for the widowed. In R. Price, E. 

Cowen, R. P. Lorion, & J. Ramos-McKay (Eds.), 

Fourteen ounces of prevention: A case-book for 

practitioners (pp. 175-186). Washington, DC: 

American Psychological Association. 
Size, T. (1998). Would John Wayne ask for Prozac? 

Rural Health FYI, March/April, 5-7. 
Smith, H., & Allison, R. (1998). The national telemental 

health report. Washington, DC: Department of 

Health and Human Services, Center for Mental 

Health Services and the Office of Rural Health 

Policy. 
Snowden L. R. (1998). Barriers to effective mental 

health services for African Americans. Manuscript 

submitted for publication. 
Snowden, L. R. (1999). Mental health system reform 

and ethnic minority populations. Manuscript 

submitted for publication. 
Snowden, L. R. (in press-a). African American service 

use for mental health problems. Journal of 

Community Psychology. 
Snowden, L. R. (in press-b). Inpatient mental health use 

by members of ethnic minority groups. In J. M. 

Herrera, W. B. Lawson, & J. J. Smerck (Eds.), 

Cross cultural psychiatry. Chichester, England: 

John Wiley. 
Snowden, L. R., & Hu, T. W. (1996). Outpatient service 

use in minority-serving mental health programs. 

Administration and Policy in Mental Health, 24, 

149-159. 
Snowden, L. R., & Cheung, F. K. (1990). Use of 

inpatient mental health services by members of 

ethnic minority groups. American Psychologist, 45, 

347-355. 
Snowden, L. R., Hu, T. W., & Jerrell, J. M. (1995). 

Emergency care avoidance: Ethnic matching and 

participation in minority-serving programs. 

Community Mental Health Journal, 31, 463-473. 



Snowden, L., Storey, C, & Clancy, T. (1989). Ethnicity 
and continuation in treatment at a black community 
mental health center. Journal of Community 
Psychology, 77, 111-118. 

South Carolina SHARE (1995). National directory of 
mental health consumer and ex-patient 
organizations and resources. Charlotte, SC: Author. 

Spaniol, L. J., Gagne, C, & Koehler, M. (1997). 
Psychological and social aspects of psychiatric 
disability. Boston, MA: Center for Psychiatric 
Rehabilitation, Sargent College of Allied Health 
Professions, Boston University. 

Specht, D. (Ed.). (1998). Highlights of the findings of a 
national survey on state support of consumer/ex- 
patients activities. Holyoke, MA: Human Resource 
Association of the Northeast. 

Srole, L. (1962). Mental health in the metropolis: The 
Midtown Manhattan study. New York: McGraw- 
Hill. 

Stocks, M. L. (1995). In the eye of the beholder. 
Psychiatric Rehabilitation Journal, 19, 89-91. 

Sue, S., Fujino, D. C, Hu, L. T., Takeuchi, D. T., & 
Zane, N. W. (1991). Community mental health 
services for ethnic minority groups: A test of the 
cultural responsiveness hypothesis. Journal of 
Consulting and Clinical Psychology, 59, 533-540. 

Sue, S., & McKinney, H. (1975). Asian Americans in 
the community mental health care system. American 
Journal of Orthopsychiatry, 45, 111-118. 

Sue, S., Zane, N., & Young, K. (1994). Research on 
psychotherapy with culturally diverse populations. 
In A. E. Bergin & S. L. Garfield (Eds.), Handbook 
of psychotherapy and behavior change (4th ed., pp. 
783-817). New York: Wiley. 

Sullivan, W. P. (1994). A long and winding road: The 
process of recovery from severe mental illness. 
Innovations and Research, 3, 19-27. 

Sullivan, G. M., Coplan, J. D., & Gorman, J. M. (1998). 
Psychoneuroendocrinology of anxiety disorders. 
Psychiatric Clinics of North America, 21, 397-412. 

Sussman, L. K., Robins, L. N., & Earls, F. (1987). 
Treatment-seeking for depression by black and 
white Americans. Social Science and Medicine, 24, 
187-196. 



115 



Mental Health: A Report of the Surgeon General 



Takeuchi, D. T., Sue, S., & Yeh, M. (1995). Return 
rates and outcomes from ethnicity-specific mental 
health programs in Los Angeles. American Journal 
of Public Health, 85, 638-643. 

Takeuchi, D. T., & Uehara, E. S. (1996). Ethnic 
minority mental health services: Current research 
and future conceptual directions. In B. L. Levin & 
J. Petrila (Eds.), Mental health services: A public 
health perspective (pp. 63-80). New York: Oxford 
University Press. 

Taylor, O. (1989). The effects of cultural assumptions 
on cross-cultural communication. In D. Koslow & 
E. Salett (Eds.), Crossing cultures in mental health 
(pp. 18-27). Washington, DC: SIETAR 
International. 

Taylor, R. J. (1986). Religious participation among 
elderly blacks. Gerontologist, 26, 630-636. 

Thompson, J. (1997). The help-seeking behavior of 
minorities. Closing the Gap, 8. 

Turner, J., & TenHoor, W. (1978). The NIMH 
community support program: Pilot approach to a 
needed social reform. Schizophrenia Bulletin, 4, 
319-348. 

Uba, L. (1994). Asian Americans: Personality patterns, 
identity, and mental health. New York: Guilford 
Press. 

U.S. Census Bureau. (1999). Resident population of the 
United States by sex, race, and Hispanic origin . 
[On-line]. Available: www.census.gov/population/ 
estimates/ nation/intfile3-l.txt 

U.S. Department of Education. (1990). Training 
students with learning disabilities for careers in the 
human services. OSERS News in Print! ///(3). 

Van Tosh, L., & del Vecchio, P. (in press). 
Consumer/survivor-operated self-help programs: A 
technical report. Washington, DC: U.S. Department 
of Health and Human Services. 

Vega, W. A., & Kolody, B. (1998). Hispanic mental 
health at the crossroads. Manuscript submitted for 
publication. 

Vega, W. A., Kolody, B., Aguilar-Gaxiola, S., Alderete, 
E., Catalano, R., & Caraveo-Anduaga, J. (1998a). 
Lifetime prevalence of DSM-III-R psychiatric 
disorders among urban and rural Mexican 
Americans in California. Archives of General 
Psychiatry, 55, 771-778. 



Waldrop, M. M. (1993). Cognitive neuroscience: A 
world with a future. Science, 261, 1805-1807. 

Weissman, M. M., Myers, J. K., & Harding, P. S. 
(1978). Psychiatric disorders in a U.S. urban 
community: 1975-1976. American Journal of 
Psychiatry, 135, 459-462. 

Wells, K. B., & Sturm, R. (1996). Informing the policy 
process: From efficacy to effectiveness data on 
pharmacotherapy. Journal of Consulting and 
Clinical Psychology, 64, 638-645. 

Werner, E. E., & Smith, R. S. (1992). Overcoming the 
odds: High risk children from birth to adulthood. 
New York: Cornell Unviersity Press. 

Wolfe, B. E., & Goldfried, M. R. (1988). Research on 
psychotherapy integration: Recommendations and 
conclusions from an NIMH workshop. Journal of 
Consulting and Clinical Psychology, 56, 448-451. 

World Health Organization. (1992). International 
statistical classification of diseases and related 
health problems (10th revision, ICD-10). Geneva: 
Author. 

Yalom, I. D. (1995). The theory and practice of group 
psychotherapy (4th ed.). New York: Basic Books. 

Yeh, M., Takeuchi, D., & Sue, S. (1994). Asian 
American children in the mental health system: A 
comparison of parallel and mainstream outpatient 
service centers. Journal of Clinical Child 
Psychology, 23, 5-12. 

Yehuda, R. (1999). Biological factors associated with 
susceptibility to post-traumatic stress disorder. 
Canadian Journal of Psychiatry, 44, 34-39. 

Zhang, A. Y., Snowden, L. R., & Sue, S. (1998). 
Differences between Asian and white Americans' 
help-seeking patterns in the Los Angeles area. 
Journal of Community Psychology, 26, 317-326. 

Zhang, A., & Snowden, L. R. (in press). Ethnic 
characteristics of mental disorders in five 
communities nationwide. Cultural Diversity and 
Mental Health. 

Zinman, S., Harp, H. T., & Budd, S. (1987). Reaching 
across. Riverside, CA: California Network of 
Mental Health Clients. 

Zunzunegui, M. V., Beland, F., Laser, A., , & Leon, V. 
(1998). Gender difference in depressive symptoms 
among Spanish elderly. Social Psychiatry 
Psychiatric Epidemiology, 5, 175-205. 



116 



Chapter 3 

Children and Mental Health 



Contents 



Normal Development 124 

Theories of Development 124 

Development Viewed as a Series of Stages 125 

Intellectual Development 125 

Behavioral Development 125 

Social and Language Development 125 

Parent-Child Relationships 125 

Origins of Language 126 

Relationships With Other Children 126 

Temperament 127 

Developmental Psychopathology 127 

Current Developmental Theory Applied to Child Mental Health and Illness 127 

Overview of Risk Factors and Prevention 129 

Risk Factors 129 

Biological Influences on Mental Disorders 129 

Psychosocial Risk Factors 130 

Family and Genetic Risk Factors 131 

Effects of Parental Depression 131 

Stressful Life Events 131 

Childhood Maltreatment 132 

Peer and Sibling Influences 132 

Correlations and Interactions Among Risk Factors 132 

Prevention 132 

Project Head Start 133 

Carolina Abecedarian Project 134 

Infant Health and Development Program 134 



Contents, continued 



Elmira Prenatal/Early Infancy Project 134 

Primary Mental Health Project 135 

Other Prevention Programs and Strategies 136 

Overview of Mental Disorders in Children 136 

General Categories of Mental Disorders of Children 136 

Assessment and Diagnosis 137 

Evaluation Process 138 

Treatment Strategies 139 

Psychotherapy 140 

Psychopharmacology 140 

Attention-Deficit/Hyperactivity Disorder 142 

Prevalence 144 

Causes 144 

Treatment 146 

Pharmacological Treatment 146 

Psychostimulants 146 

Dosing 146 

Side Effects 146 

Other Medications 147 

Psychosocial Treatment 147 

Behavioral Approaches 147 

Cognitive-Behavioral Therapy 148 

Psychoeducation 148 

Multimodal Treatments 148 

Treatment Controversies 149 

Overprescription of Stimulants 149 

Safety of Long-Term Stimulant Use 150 



Contents, continued 



Depression and Suicide in Children and Adolescents 150 

Conditions Associated With Depression 151 

Prevalence 151 

Major Depression 151 

Dysthymic Disorder 152 

Suicide 152 

Course and Natural History 152 

Causes 153 

Family and Genetic Factors 153 

Gender Differences 153 

Biological Factors 153 

Cognitive Factors 154 

Risk Factors for Suicide and Suicidal Behavior 154 

Consequences 155 

Treatment 155 

Depression 155 

Psychosocial Interventions 155 

Pharmacological Treatment 156 

Bipolar Disorder 157 

Pharmacological Treatment 157 

Suicide 157 

Psychotherapeutic Treatments 157 

Psychopharmacological Treatments 158 

Intervention After a Suicidal Death of a Relative, Friend, or Acquaintance 158 

Community-Based Suicide Prevention 159 

Crisis Hothnes 159 

Method Restriction 159 

Media Counseling 159 

Indirect Case-Finding Through Education 159 

Direct Case-Finding 160 

Aggressive Treatment of Mood Disorders 160 

Air Force Suicide Prevention Program — A Community Approach 160 

Other Mental Disorders in Children and Adolescents 160 

Anxiety Disorders 160 



Contents, continued 



Separation Anxiety Disorder 160 

Generalized Anxiety Disorder 161 

Social Phobia 161 

Treatment of Anxiety 162 

Obsessive-Compulsive Disorder 162 

Autism . 163 

Treatment 163 

Disruptive Disorders 164 

Treatment 166 

Substance Use Disorders in Adolescents 166 

Eating Disorders 167 

Services Interventions 168 

Treatment Interventions 168 

Outpatient Treatment 168 

Partial Hospitalization/Day Treatment 169 

Residential Treatment Centers 169 

Inpatient Treatment 171 

Newer Community-Based Interventions 172 

Case Management 172 

Team Approaches to Case Management 174 

Home-Based Services 175 

Family Preservation Programs Under the Child Welfare System 175 

Multisystemic Therapy 175 

Therapeutic Foster Care 176 

Therapeutic Group Homes 177 

Crisis Services 178 

Service Delivery 179 

Service Utilization 180 

Utilization in Relation to Need 180 

Early Termination of Treatment 180 

Poverty and Utilization 181 

Culture and Utilization 181 



Contents, continued 



Service Systems and Financing 182 

Private Sector 182 

Public Sector 183 

Children Served by the Public Sector 184 

Managed Care in the Public Sector 185 

Culturally Appropriate Social Support Services 186 

Support and Assistance for Families 187 

New Roles for Families in Systems of Care 188 

Family Support 188 

Family Support Groups 189 

Practical Support 190 

Integrated System Model 190 

Effectiveness of Systems of Care 191 

The Fort Bragg Study 191 

The Stark County Study 192 

Summary: Effectiveness of Systems of Care 193 

Conclusions 193 

References 194 



Chapter 3 

Children and Mental Health 



Spanning roughly 20 years, childhood and 
adolescence are marked by dramatic changes in 
physical, cognitive, and social-emotional skills and 
capacities. Mental health in childhood and adolescence 
is defined by the achievement of expected 
developmental cognitive, social, and emotional 
milestones and by secure attachments, satisfying social 
relationships, and effective coping skills. Mentally 
healthy children and adolescents enjoy a positive 
quality of life; function well at home, in school, and in 
their communities; and are free of disabling symptoms 
of psychopathology (Hoagwood et al., 1996). 

The basic principles for understanding health and 
illness discussed in the previous chapter apply to 
children and adolescents, but it is important to 
underscore the often heard admonition that "children 
are not little adults." Even more than is true for adults, 
children must be seen in the context of their social 
environments, that is, family, peer group, and their 
larger physical and cultural surroundings. Childhood 
mental health is expressed in this context, as children 
proceed through development. 

Development, characterized by periods of transition 
and reorganization, is the focus of much research on 
children and adolescents. Studies focus on normal and 
abnormal development, trying to understand and 
predict the forces that will keep children and 
adolescents mentally healthy and maintain them on 
course to become mentally healthy adults. These 
studies ask what places some at risk for mental illness 
and what protects some but not others, despite exposure 
to the same risk factors. 

In addition to studies of normal development and of 
risk factors, much additional research focuses on 
mental illness in childhood and adolescence and what 
can be done to prevent or treat it. The science is 



challenging because of the ongoing process of 
development. The normally developing child hardly 
stays the same long enough to make stable 
measurements. Adult criteria for illness can be difficult 
to apply to children and adolescents, when the signs 
and symptoms of mental disorders are often also the 
characteristics of normal development. For example, a 
temper tantrum could be an expected behavior in a 
young child but not in an adult. At some point, 
however, it becomes clearer that certain symptoms and 
behaviors cause great distress and may lead to 
dysfunction of children, their family, and others in their 
social environment. At these points, it is helpful to 
consider serious deviations from expected cognitive, 
social, and emotional development as "mental 
disorders." Specific treatments and services are 
available for children and adolescents with such mental 
disorders, but one cannot forget that these disorders 
emerge in the context of an ongoing developmental 
process and shifting relationships within the family and 
community. These developmental factors must be 
carefully addressed, if one is to maximize the healthy 
development of children with mental disorders, 
promote remediation of associated impairments, and 
enhance their adult outcomes. 

The developmental perspective helps us understand 
how estimated prevalence rates for mental disorders in 
children and adolescents vary as a function of the 
degree of impairment that the child experiences in 
association with specific symptom patterns. For 
example, the MECA Study (Methodology for 
Epidemiology of Mental Disorders in Children and 
Adolescents) estimated that almost 21 percent of U.S. 
children ages 9 to 17 had a diagnosable mental or 
addictive disorder associated with at least minimum 
impairment (see Table 3-1). When diagnostic criteria 



123 



Mental Health: A Report of the Surgeon General 



Table 3-1. Children and adolescents age 9-17 with 
mental or addictive disorders, combined 
MECA sample, 6-month (current) prevalence* 



(%) 


Anxiety Disorders 


13.0 


IVlood Disorders 


6.2 


Disruptive Disorders 


10.3 


Substance Use Disorders 


2.0 


Any Disorder 


20.9 



* Disorders include diagnosis-specific impairment and Ciiild 
Global Assessment Scale <70 (mild global impairment) 

Source: Shaffer et al., 1996a 

required the presence of significant functional impair- 
ment, estimates dropped to 1 1 percent. This estimate 
translates into a total of 4 million youth who suffer 
from a major mental illness that results in significant 
impairments at home, at school, and with peers. 
Finally, when extreme functional impairment is the 
criterion, the estimates dropped to 5 percent. 

Given the process of development, it is not 
surprising that these disorders in some youth are known 
to wax and wane, such that some afflicted children 
improve as development unfolds, perhaps as a result of 
healthy influences impinging on them. Similarly, other 
youth, formerly only "at risk," may develop full-blown 
forms of disorder, as severe and devastating in their 
impact on the youth and his or her family as are the 
analogous conditions that affect adults. Characterizing 
such disorders as relatively unchangeable under- 
estimates the potential beneficial influences that can 
redirect a child whose development has gone awry. 
Likewise, characterizing children with mental disorders 
as "only" the victims of negative environmental 
influences that might be fixed if societal factors were 
just changed runs the risk of underestimating the 
severity of these conditions and the need for focused, 
intensive clinical interventions for suffering children 
and adolescents. Thus, the science of mental health in 
childhood and adolescence is a complex mix of the 
study of development and the study of discrete 



conditions or disorders. Both perspectives are useful. 
Each alone has its limitations, but together they 
constitute a more fully informed approach that spans 
mental health and illness and allows one to design 
developmentally informed strategies for prevention and 
treatment. 

Normal Development 

Development is the lifelong process of growth, matur- 
ation, and change that unfolds at the fastest pace during 
childhood and adolescence. An appreciation of normal 
development is crucial to understanding mental health 
in children and adolescents and the risks they face in 
maintaining mental health. Distortions in the process of 
development may lead to mental disorders. This section 
deals with the normal development of understanding 
(cognitive development) in young children and the 
development of social relationships and temperament. 

Theories of Development 

Historically, the changes that take place in a child's 
psyche between birth and adulthood were largely 
ignored. Child development first became a subject of 
serious inquiry at the beginning of this century but was 
mostly viewed from the perspective of mental disorders 
and from the cultural mainstream of Europe and white 
America. Some of the "grand theories" of child 
development, such as that propounded by Sigmund 
Freud, grew out of this focus, and they unquestionably 
drew attention to the importance of child development 
in laying the foundation for adult mental health. Even 
those theories that resulted from the observation of 
healthy children, such as Piaget's theory of cognitive 
development, paid little attention to the relationship 
between the development of the "inner self and the 
environment into which the individual was placed. In 
contrast, the interaction of an individual with the 
environment was central to the school of thought 
known as behaviorism. 

Theories of normal development, introduced in 
Chapter 2, are presented briefly below, because they 
form the basis of many current approaches to 
understanding and treating mental illness and mental 
health problems in children and adults. These theories 



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Children and Mental Health 



have not achieved the broader objective of explaining 
how children grow into healthy adults. More study and 
perhaps new theories will be needed to improve our 
ability to guide healthy child-rearing with scientific 
evidence. 

Development Viewed as a Series of Stages 

Freud and the psychoanalyst Erik Erikson proposed a 
series of stages of development reflecting the 
attainment of biological objectives. The stages are 
expressed in terms of functioning as an individual and 
with others — within the family and the broader social 
environment (particularly in Erikson' s theories) (see 
Chapter 2). Although criticized as unscientific and 
relevant primarily to the era and culture in which they 
were conceived, these theories introduced the 
importance of thinking developmentally, that is, of 
considering the ever-changing physical and 
psychological capacities and tasks faced by people as 
they age. They emphasized the concept of "maturation" 
and moving through the stages of life, adapting to 
changing physical capacities and new psychological 
and social challenges. And they described mental 
health problems associated with failure to achieve 
milestones and objectives in their developmental 
schemes. 

These theories have guided generations of 
psychodynamic therapists and child development 
experts. They are important to understand as the 
underpinnings of many therapeutic approaches, such as 
interpersonal therapy, some of which have been 
evaluated and found to be efficacious for some 
conditions. By and large, however, these theories have 
rarely been tested empirically. 

Intellectual Development 

The Swiss psychologist Jean Piaget also developed a 
stage-constructed theory of children's intellectual 
development. Piaget' s theory, based on several 
decades' observations of children (Inhelder & Piaget, 
1958), was about how children gradually acquire the 
ability to understand the world around them through 
active engagement with it. He was the first to recognize 
that infants take an active role in getting to know their 



world and that children have a different understanding 
of the world than do adults. The principal limitations of 
Piaget' s theories are that they are descriptive rather 
than explanatory. Furthermore, he neglected variability 
in development and temperament and did not consider 
the crucial interplay between a child's intellectual 
development and his or her social experiences (Bidell 
& Fischer, 1992). 

Behavioral Development 

Other approaches to understanding development are 
less focused on the stages of development. Behavioral 
psychology focused on observation and measurement, 
explaining development in terms of responses to 
stimuli, such as rewards. Not only did the theories of 
the early pioneers (e.g., Pavlov, Watson, and Skinner) 
generate a number of valuable treatments, but their 
focus on precise description set the stage for current 
programs of research based on direct observation. 
Social learning theory (Bandura, 1977) emphasized role 
models and their impact on children and adolescents as 
they develop. Several important clinical tools came out 
of behaviorism (e.g., reinforcement and behavior 
modification) and social learning theory (cognitive- 
behavioral therapy). Both treatment approaches are 
used effectively with children and adolescents. 

Social and Language Development 

Parent-Child Relationships 

It is common knowledge that infants and, for the most 
part, their principal caretakers typically develop a close 
bond during the first year of life, and that in the second 
year of life children become distressed when they are 
forcibly separated from their mothers. However, the 
clinical importance of these bonds was not fully 
appreciated until John Bowlby introduced the concept 
of attachment in a report on the effects of maternal 
deprivation (Bowlby, 195 1 ). Bowlby (1969) postulated 
that the pattern of an infant's early attachment to 
parents would form the basis for all later social 
relationships. On the basis of his experience with 
disturbed children, he hypothesized that, when the 
mother was unavailable or only partially available 



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Mental Health: A Report of the Surgeon General 



during the first months of the child's hfe, the 
attachment process would be interrupted, leaving 
enduring emotional scars and predisposing a child to 
behavioral problems. 

A mother's bond with her child often starts when 
she feels fetal movements during pregnancy. 
Immediately after birth, most, but by no means all, 
mothers experience a surge of affection that is followed 
by a feeling that the baby belongs to them. This 
experience may not occur at all or be delayed under 
conditions of addiction or postnatal depression (Robson 
& Kumar, 1980; Kumar, 1997). Yet, like all enduring 
relationships, it seems that the relationship between 
mother and child develops gradually and strengthens 
overtime. Some infants who experience severe neglect 
in early life may develop mentally and emotionally 
without lasting consequences, for example, if they are 
adopted and their adoptive parents provide sensitive, 
stable, and enriching care, or if depressed or substance- 
abusing mothers recover fully (Koluchova, 1972; 
Dennis, 1973; Downey & Coyne, 1990). Unfortunately, 
however, early neglect is all too often the precursor of 
later neglect. When the child remains subject to 
deprivation, inadequate or insensitive care, lack of 
affection, low levels of stimulation, and poor education 
over long periods of time, later adjustment is likely to 
be severely compromised (Dennis, 1973; Curtiss, 
1977). 

In general, it appears that the particular caregiver 
with whom infants interact (i.e., biological mother or 
another) is less important for the development of good 
social relationships than the fact that infants interact 
over a period of time with someone who is familiar and 
sensitive (Lamb, 1975; Bowlby, 1988). One of the 
problems in the later development of children who 
experience early institutionalization or significant 
neglect is that there may have been no opportunities for 
the caretakers and the infants to establish strong and 
mutual attachments in a reciprocating relationship. 

Origins of Language 

Recent research has established that successful use of 
language and communication is a cornerstone of 
childhood mental health. Not only are strong language 



capabilities critical to the development of such skills as 
listening and speaking, but they also are fundamental to 
the acquisition of proficient reading and writing 
abilities. In turn, children with a variety of speech and 
language impediments are at increasing risk as their 
language abilities fall behind those of their peers. 
Caretaker and baby start to communicate with each 
other vocally as well as visually during the first months 
of life. Many, but not all, developmental psychologists 
believe that this early pattern of mother-infant 
reciprocity and interchange is the basis on which 
subsequent language and communication develop. 
Various theorists have attempted to explain the 
relations between language and cognitive development 
(Vygotsky, 1962; Chomsky, 1965, 1975, 1986;Bruner, 
1971; Luria, 1971), but no single theory has achieved 
preeminence. While a number of theories address 
language development from different perspectives, all 
theories suggest that language development depends on 
both biological and socio-environmental factors. It is 
clear that language competence is a critical aspect of 
children's mental health. 

Relationships With Other Children 

To be healthy, children must form relationships not 
only with their parents, but also with siblings and with 
peers. Peer relationships change over time. In the 
toddler period, children's social skills are very limited; 
they spend most of their time playing side by side 
rather than with each other in a give-and-take fashion. 
As children grow, their abilities to form close 
relationships become highly dependent on their social 
skills. These include an ability to interpret and 
understand other children's nonverbal cues, such as 
body language and pitch of voice. Children whose 
social skills develop optimally respond to what other 
children say, use eye contact, often mention the other 
child's name, and may use touch to get attention. If 
they want to do something that other children oppose, 
they can articulate the reasons why their plan is a good 
one. They can suppress their own wishes and desires to 
reach a compromise with other children and may be 
willing to change — at least in the presence of another 
child — a stated belief or wish. When they are with a 



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Children and Mental Health 



group of children they do not know, they are quiet but 
observant until they have a feeling for the structure and 
dynamics of the group (Coie & Kuperschmidt, 1983; 
Dodge, 1983; Putallaz, 1983; Dodge & Feldman, 1990; 
Kagan et al., 1998). 

In contrast, children who lack such skills tend to be 
rejected by other children. Commonly, they are 
withdrawn, do not listen well, and offer few if any 
reasons for their wishes; they rarely praise others and 
find it difficult to join in cooperative activities (Dodge, 
1983). They often exhibit features of oppositional 
defiant or conduct disorder, such as regular fighting, 
dominating and pushing others around, or being 
spiteful (Dodge et al., 1990). Social skills improve with 
opportunities to mix with others (Bridgeman, 1981). In 
recent years, knowledge of the importance of children' s 
acquisition of social skills has led to the development 
and integration of social skills training components into 
a number of successful therapeutic interventions. 

Temperament 

During the past two decades, as psychologists began to 
view the child less as a passive recipient of 
environmental input but rather as an active player in the 
process, the importance of temperament has become 
better appreciated (Plomin, 1986). Temperament is 
defined as the repertoire of traits with which each child 
is bom; this repertoire determines how people react to 
the world around them. Such variations in character- 
istics were &st described systematically by Anna 
Freud from her observations of children orphaned by 
the ravages of World War n. She noticed that some 
children were affectionate, some wanted to be close but 
were too shy to approach adults, and some were 
difficult because they were easily angered and 
frustrated (A. Freud, 1965). 

The first major longitudinal observations on 
temperament were begun in the 1950s by Thomas and 
Chess (1977). They distinguished 10 aspects of 
temperament, but there appear to be many different 
ways to describe temperamental differences (Goldsmith 
et al., 1987). Although there is some continuity in 
temperamental qualities throughout the hfe span (Chess 



& Thomas, 1984; Mitchell, 1993), temperament is 
often modified during development, particularly by the 
interaction with the caregiver. For example, a timid 
child can become bolder with the help of parental 
encouragement (Kagan, 1984, 1989). Some traits of 
temperament, such as attention span, goal orientation, 
lack of distractibility, and curiosity, can affect 
cognitive functioning because the more pronounced 
these traits are, the better a child will learn (Campos et 
al., 1983). Of note, it is not always clear whether 
extremes of temperament should be considered within 
the spectrum of mental disorder (for example, shyness 
or anxiety) or whether certain forms of temperament 
might predispose a child to the development of certain 
mental disorders. 

Developmental Psychopathology 

Current Developmental Theory Applied to Child 
Mental Health and Illness 

A number of central concepts and guiding assumptions 
underpin our current understanding of children's 
mental health and illness. These have been variously 
defined by different investigators (Sroufe & Rutter, 
1984; Cicchetti & Cohen, 1995; Jensen, 1998), but by 
and large these tenets are based on the premise that 
psychopathology in childhood arises from the complex, 
multilayered interactions of specific characteristics of 
the child (including biological, psychological, and 
genetic factors), his or her environment (including 
parent, sibling, and family relations, peer and 
neighborhood factors, school and community factors, 
and the larger social-cultural context), and the specific 
manner in which these factors interact with and shape 
each other over the course of development. Thus, an 
understanding of a child's particular history and past 
experiences (including biologic events affecting brain 
development) is essential to unravel the why's and 
wherefore's of a child's particular behaviors, both 
normal and abnormal. 

While this principle assumes developmental 
continuities, to the extent that early experiences are 
"brought forward" into the current behavior, it is also 



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Mental Health: A Report of the Surgeon General 



important to consider developmental discontinuities, 
where qualitative shifts in the child's biological, 
psychological, and social capacities may occur. These 
may not be easily discerned or predicted ahead of time 
and may reflect the emergence of new capacities (or 
incapacities) as the child's psychological self, brain, 
and social environment undergo significant 
reorganization. 

A second precept underlying an adequate 
understanding of children's mental health and illness 
concerns the innate tendencies of the child to adapt to 
his or her environment. This principle of adaptation 
incorporates and acknowledges children's "self- 
righting" and "self-organizing" tendencies; namely, that 
a child within a given context naturally adapts (as much 
as possible) to a particular ecological niche, or when 
necessary, modifies that niche to get needs met. When 
environments themselves are highly disordered or 
pathological, children's adaptations to such settings 
may also be pathologic, especially when compared with 
children's behaviors within more healthy settings. This 
principle underscores the likelihood that some (but not 
all) "pathologic" behavioral syndromes might be best 
characterized as adaptive responses when the child or 
adolescent encounters difficult or adverse 
circumstances. Notably, this ability to adapt 
behaviorally is reflected at multiple levels, including 
the level of brain and nervous system structures 
(sometimes called neuroplasticity). 

A third consideration that guides both research- 
based and clinical approaches to understanding child 
mental health and illness concerns the importance of 
age and timing factors. For example, a behavior that 
may be quite normal at one age (e.g., young children's 
distress when separated from their primary caretaking 
figure) can be an important symptom or indicator of 
mental illness at another age. Similarly, stressors or risk 
factors may have no, little, or profound impact, 
depending on the age at which they occur and whether 
they occur alone or with other accumulated risk factors. 

A fourth premise underpinning an adequate 
understanding of children's mental health and illness 
concerns the importance of the child's context. Perhaps 



the most important context for developing children is 
their caretaking environment. Research with both 
humans and animals has demonstrated that gross 
disruptions in this critical parameter have immediate 
and long-term effects, not just on the young organism's 
later social-emotional development but also on physical 
health, long-term morbidity and mortality, later 
parenting practices, and even behavioral outcomes of 
its offspring. Moreover, context may play a role in the 
definition of what actually constitutes psychopathology 
or health. The same behavior in one setting or culture 
might be acceptable and even "normative," whereas it 
may be seen as pathological in another. 

Yet another principle central to understanding child 
mental health and illness is that normal and abnormal 
developmental processes are often separated only by 
differences of degree. Thus, supposed differences 
between normal and abnormal behavior may be better 
understood by taking into account the differences in the 
amount or degree of the particular behavior, or the 
degree of exposure to a particular risk factor. 
Frequently, no sharp distinctions can be made. 

The virtue of these developmental considerations 
when applied to children is that (a) they enable a 
broader, more informed search for factors related to the 
onset of, maintenance of, and recovery from abnormal 
forms of child behavior; (b) they help move beyond 
static diagnostic terms that tend to reduce the behaviors 
of a complex, developing, adapting, and feeling child to 
an oversimplified diagnostic term; (c) they offer a new 
perspective on potential targets for intervention, 
whether child-focused or directed toward 
environmental or contextual factors; and (d) they 
highlight the possibility of important timing 
considerations: windows of opportunity during a 
child's development when preventive or treatment 
interventions may be especially effective. 

In the sections that follow, these considerations 
will help the reader understand the important 
differences from chapters focusing principally on 
adults, as well as the unique opportunities for 
intervention that occur because of these differences. 



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Children and Mental Health 



Overview of Risk Factors and 
Prevention 

Current approaches to understanding the etiology of 
mental disorders in childhood are driven by empirical 
advances in neuroscience and behavioral research 
rather than by theories. Epidemiological research on the 
factors that make children vulnerable to mental illness 
is important for several reasons: delineating the range 
of risk factors for particular mental disorders helps to 
understand their etiology; the populations most at risk 
can be identified; understanding the relative strength of 
different risk factors allows for the design of 
appropriate prevention programs for children in 
different contexts; and resources can be better allocated 
to intervene so as to maximize their effectiveness. 

Risk Factors 

There is nov^ good evidence that both biological factors 
and adverse psychosocial experiences during childhood 
influence — but not necessarily "cause" — the mental 
disorders of childhood. Adverse experiences may occur 
at home, at school, or in the community. A stressor or 
risk factor may have no, little, or a profound impact, 
depending on individual differences among children 
and the age at which the child is exposed to it, as well 
as whether it occurs alone or in association with other 
risk factors. Although children are influenced by their 
psychosocial environment, most are inherently resilient 
and can deal with some degree of adversity. However, 
some children, possibly those with an inherent 
biological vulnerability (e.g., genes that convey 
susceptibility to an illness), are more likely to be 
harmed by an adverse environment, and there are some 
environmental adversities, especially those that are 
long-standing or repeated, that seem likely to induce a 
mental disorder in all but the hardiest of children. A 
recent analysis of risk factors by Kraemer and 
colleagues (1997) has provided a useful framework for 
differentiating among categories of risk and may help 
point this work in a more productive direction. 

Risk factors for developing a mental disorder or 
experiencing problems in social-emotional 
development include prenatal damage from exposure to 
alcohol, illegal drugs, and tobacco; low birth weight; 



difficult temperament or an inherited predisposition to 
a mental disorder; external risk factors such as poverty, 
deprivation, abuse and neglect; unsatisfactory relation- 
ships; parental mental health disorder; or exposure to 
traumatic events. 

Biological Influences on Mental Disorders 

It seems likely that the roots of most mental disorders 
lie in some combination of genetic and environmental 
factors — the latter may be biological or psychosocial 
(Rutter et al., 1999). However, increasing consensus 
has emerged that biologic factors exert especially 
pronounced influences on several disorders in par- 
ticular, including pervasive developmental disorder 
(Piven & O'Leary, 1997), autism (Piven & O'Leary, 
1997), and early-onset schizophrenia (McClellan & 
Werry, in press). It is also likely that biological factors 
play a large part in the etiology of social phobia (Pine, 
1997), obsessive-compulsive disorder (Leonard et al., 
1997), and other disorders such as Tourette's disorder 
(Leckman et al., 1997). 

Two important points about biological factors 
should be borne in mind. The first is that biological 
influences are not necessarily synonymous with those 
of genetics or inheritance. Biological abnormalities of 
the central nervous system that influence behavior, 
thinking, or feeling can be caused by injury, infection, 
poor nutrition, or exposure to toxins, such as lead in the 
environment. These abnormalities are not inherited. 
Mental disorders that are most likely to have genetic 
components include autism, bipolar disorder, 
schizophrenia, and attention-deficit/hyperactivity 
disorder (ADHD) (National Institute of Mental Health 
[NIMH], 1998). Second, it is erroneous to assume that 
biological and environmental factors are independent of 
each other, when in fact they interact. For example, 
traumatic experiences may induce biological changes 
that persist. Conversely, children with a biologically 
based behavior may modify their environment. For 
example, low-birth-weight infants who have sustained 
brain damage, and thereby become excessively 
irritable, may change the behavior of caretakers in a 
way that adversely affects the caretaker's ability to 
provide good care. Thus, it is now well documented 



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Mental Health: A Report of the Surgeon General 



that a number of biologic risk factors exert important 
effects on brain structure and function and increase the 
likehhood of subsequently developing mental dis- 
orders. These well-established factors include intra- 
uterine exposure to alcohol or cigarette smoke (Nichols 
& Chen, 1981), perinatal trauma (Whitaker et al., 
1997), environmental exposure to lead (Needleman et 
al., 1990), malnutrition of pregnancy, traumatic brain 
injury, nonspecific forms of mental retardation, and 
specific chromosomal syndromes. 

Psychosocial Risk Factors 

A landmark study on risks from the environment 
(Rutter & Quinton, 1977) showed that several factors 
can endanger a child's mental health. Dysfunctional 
aspects of family life such as severe parental discord, 
a parent's psychopathology or criminality, 
overcrowding, or large family size can predispose to 
conduct disorders and antisocial personality disorders, 
especially if the child does not have a loving 
relationship with at least one of the parents (Rutter, 
1979). Economic hardship can indirectly increase a 
child' s risk of developing a behavioral disorder because 
it may cause behavioral problems in the parents or 
increase the risk of child abuse (Dutton, 1986; Link et 
al., 1986; Wilson, 1987; Schorr, 1988). Exposure to 
acts of violence also is identified as a possible cause of 
stress-related mental health problems (Jenkins & Bell, 
1997). Studies point to poor caregiving practices as 
being a risk factor for children of depressed parents 
(Zahn-Waxler et al., 1990). 

The quality of the relationship between infants or 
children and their primary caregiver, as manifested by 
the security of attachment, has long been felt to be of 
paramount importance to mental health across the hfe 
span. In this regard, the relationship between maternal 
problems and those factors in children that predispose 
them to form insecure attachments, particularly young 
infants' and toddlers' security of attachment and 
temperament style and their impact on the development 
of mood and conduct disorders, is of great interest to 
researchers. Many investigators have taken the view 
that the nature and the outcome of the attachment 
process are related to later depression, especially when 



the child is raised in an abusive environment (Toth & 
Cicchetti, 1996), and to later conduct disorder 
(Sampson & Laub, 1993). The relationship of 
attachment to mental disorders has been the subject of 
several important review articles (Rutter, 1995; van 
IJzendoorn et al., 1995). 

There is controversy as to whether the key 
determinant of "insecure" responses to strange 
situations stems from maternal behavior or from an 
inborn predisposition to respond to an unfamiliar 
stranger with avoidant behaviors, such as is found in 
socially phobic children (Belsky & Rovine, 1987; 
Kagan et al., 1988; Thompson et al., 1988; Kagan, 
1994, 1995). Kagan demonstrated that infants who 
were more prone to being active, agitated, and tearful 
at 4 months of age were less spontaneous and sociable 
and more likely to show anxiety symptoms at age 4 
(Snidman et al., 1995; Kagan et al., 1998). These 
findings are of considerable significance, because long- 
term study of such highly reactive, behaviorally 
inhibited infants and toddlers has shown that they are 
excessively shy and avoidant in early childhood and 
that this behavior persists and predisposes to later 
anxiety (Biederman et al., 1993). There is also some 
controversy as to whether "difficult" temperament in an 
infant is an early manifestation of a behavior problem, 
particularly in children who go on to demonstrate such 
problems as conduct disorder (Olds et al., 1999). One 
analysis of the attachment literature suggests that 
abnormal or insecure forms of attachment are largely 
the product of maternal problems, such as depression 
and substance abuse, rather than of individual 
differences in the child (van IJzendoorn et al., 1992). 

The relationship between a child's temperament 
and parenting style is complex (Thomas et al., 1968); 
it may be either protective if it is good or a risk factor 
if it is poor. Thus, a difficult child's chances of 
developing mental health problems are much reduced 
if he or she grows up in a family in which there are 
clear rules and consistent enforcement (Maziade et al., 
1985), while a child exposed to inconsistent discipline 
is at greater risk for later behavior problems (Werner & 
Smith, 1992). 



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Children and Mental Health 



Family and Genetic Risk Factors 

As noted above in the relationships between 
temperament and attachment, in some instances the 
relative contributions of biologic influences and 
environmental influences are difficult to tease apart, a 
problem that particularly affects studies investigating 
the impact of family and genetic influences on risk for 
childhood mental disorder. For example, research has 
shown that between 20 and 50 percent of depressed 
children and adolescents have a family history of 
depression (Puig-Antichetal., 1989; Toddetal., 1993; 
WilHamson et al., 1995; Kovacs, 1997b). The exact 
reasons for this increased risk have not been fully 
clarified, but experts tend to agree that both factors 
interact to result in this increased risk (Weissman et al., 
1997). Family research has found that children of 
depressed parents are more than three times as likely as 
children of nondepressed parents to experience a 
depressive disorder (see Birmaher et al., 1996a and 
1996b for review). Parental depression also increases 
the risk of anxiety disorders, conduct disorder, and 
alcohol dependence (Downey & Coyne, 1990; 
Weissman et al., 1997; Wickramaratne & Weissman, 
1998). The risk is greater if both parents have had a 
depressive illness, if the parents were depressed when 
they were young, or if a parent had several episodes of 
depression (Merikangas et al., 1988; Downey & Coyne, 
1990; McCracken, 1992a, 1992b; Mufson et al., 1992; 
Warner et al., 1995; Wickramaratne & Weissman, 
1998). 

Effects of Parental Depression 

Depressed parents may be withdrawn and lack energy 
and consequently pay little attention to, or provide 
inadequate supervision of, their children. Alternatively, 
such parents may be excessively irritable and 
overcritical, thereby upsetting children, demoralizing 
them, and distancing them (Cohn et al., 1986; Field et 
al., 1990). At a more subtle level, parents' distress — 
being pessimistic, tearful, or threatening suicide — is 
sometimes seen or heard by the child, thereby inducing 
anxiety. Depressed parents may not model effective 
coping strategies for stress; instead of "moving on," 
some provide an example of "giving up" (Garber & 



Hilsman, 1992). Depression is also often associated 
with marital discord, which may have its own adverse 
effect on children and adolescents. Conversely, the 
behavior of the depressed child or teenager may 
contribute to family stress as much as being a product 
of it. The poor academic performance, withdrawal from 
normal peer activities, and lack of energy or motivation 
of a depressed teenager may lead to intrusive or 
reprimanding reactions from parents that may further 
reduce the youngster's self-esteem and optimism. 

The consequences of maternal depression vary with 
the state of development of the child, and some of the 
effects are quite subtle (Cicchetti & Toth, 1998). For 
example, in infancy, a withdrawn or unresponsive 
depressed mother may increase an infant' s distress, and 
an intrusive or hostile depressed mother may lead the 
infant to avoid looking at and communicating with her 
(Cohn et al., 1986). Other studies have shown that if 
infants' smiles are met with a somber or gloomy face, 
they respond by showing a similarly somber expression 
and then by averting their eyes (Murray et al., 1993). 

During the toddler stage of development, research 
shows that the playful interactions of a toddler with a 
depressed mother are often briefer and more likely to 
be interrupted (by either the mother or the child) than 
those with a nondepressed parent (Jameson et al., 
1997). Research has shown that some depressed 
mothers are less able to provide structure or to modify 
the behavior of excited toddlers, increasing the risk of 
out-of-control behavior, the development of a later 
conduct disorder, or later aggressive dealings with 
peers (Zahn-Waxler et al., 1990; Hay et al., 1992). A 
depressed mother's inability to control a young child's 
behavior may result in the child failing to learn 
appropriate skills for settling disputes without reliance 
on aggression. 

Stressful Life Events 

The relationship between stressful life events and risk 
for child mental disorders is well established (e.g., 
Garmezy, 1983; Hammen, 1988; Jensen et al., 1991; 
Garber & Hilsman, 1992), although this relationship in 
children and adolescents is complicated, perhaps 
reflecting the impact of individual differences and 



131 



Mental Health: A Report of the Surgeon General 



developmental changes. For example, there is a 
relationship between stressful life events, such as 
parental death or divorce, and the onset of major 
depression in young children, especially if they occur 
in early childhood and lead to a permanent and negative 
change in the child's circumstances. Yet findings are 
mixed as to whether the same relationship is true for 
depression in midchildhood or in adolescence 
(Birmaher et al., 1996a and 1996b; Garrison et al., 
1997). 

Childhood Maltreatment 

Child abuse is a very widespread problem; it is 
estimated that over 3 million children are maltreated 
every year in the United States (National Committee to 
Prevent Child Abuse, 1995). Physical abuse is 
associated with insecure attachment (Main & Solomon, 
1990), psychiatric disorders such as post-traumatic 
stress disorder, conduct disorder, ADHD (Famularo et 
al., 1992), depression (Kaufman, 1991), and impaired 
social functioning with peers (Salzinger et al., 1993). 
Psychological maltreatment is believed to occur more 
frequently than physical maltreatment (Cicchetti & 
Carlson, 1989); it is associated with depression, 
conduct disorder, and delinquency (Kazdin et al., 1985) 
and can impair social and cognitive functioning in 
children (Smetana & Kelly, 1989). 

Peer and Sibling Influences 

The influence of maladaptive peers can be very 
damaging to a child and greatly increases the likelihood 
of adverse outcomes such as delinquency, particularly 
if the child comes from a family beset by many 
stressors (Friday & Hage, 1976; Loeber & Farrington, 
1998). One way to reduce antisocial behavior in 
adolescents is to encourage such youths to interact with 
better adapted youths under the supervision of a mental 
health worker (Feldman et al., 1983). Sibhng rivalry is 
a common component of family life and, especially in 
the presence of other risk factors, may contribute to 
family stresses (Patterson & Dishion, 1988). Although 
almost universal, in the presence of other risk factors it 
may be the origin of aggressive behavior that 
eventually extends beyond the family (Patterson & 



Dishion, 1988). In stressed or large families, parents 
have many demands placed on their time and find it 
difficult to oversee, or place limits on, their young 
children's behavior. When parental attention is in short 
supply, young siblings squabbling with each other 
attract available attention. In such situations, parents 
rarely comment on good or neutral behavior but do pay 
attention, even if in a highly critical and negative way, 
when their children start to fight; as a result, the act of 
fighting may be inadvertently rewarded. Thus, any 
attention, whether it be praise or physical punishment, 
increases the likelihood that the behavior is repeated. 

Correlations and Interactions Among Risk 
Factors 

Recent evidence suggests that social/environmental risk 
factors may combine with physical risk factors of the 
child, such as neurological damage caused by birth 
complications or low birth-weight, fearlessness and 
stimulation-seeking behavior, learning impairments, 
autonomic underarousal, and insensitivity to physical 
pain and punishment (Raine et al, 1996, 1997, 1998). 
However, testing models of the impact of risk factor 
interactions for the development of mental disorders is 
difficult, because some of the risk factors are difficult 
to measure. Thus, the trend these days is to move away 
from the consideration of individual risk factors toward 
identifying measurable risk factors and their com- 
binations and incorporating all of them into a single 
model that can be tested (Patterson, 1996). 

The next section describes a series of preventive 
interventions directed against the environmental risk 
factors described above. 

Prevention 

Childhood is an important time to prevent mental 
disorders and to promote healthy development, because 
many adult mental disorders have related antecedent 
problems in childhood. Thus, it is logical to try to 
intervene early in children's lives before problems are 
established and become more refractory. The field of 
prevention has now developed to the point that 
reduction of risk, prevention of onset, and early 
intervention are realistic possibilities. Scientific 



132 



Children and Mental Health 



methodologies in prevention are increasingly 
sophisticated, and the results from high-quality 
research trials are as credible as those in other areas of 
biomedical and psychosocial science. There is a 
growing recognition that prevention does work; for 
example, improving parenting skills through training 
can substantially reduce antisocial behavior in children 
(Patterson et al., 1993). 

The wider human services and law enforcement 
communities, not just the mental health community, 
have made prevention a priority. Policymakers and 
service providers in health, education, social services, 
and juvenile justice have become invested in 
intervening early in children' s lives: they have come to 
appreciate that mental health is inexorably linked with 
general health, child care, and success in the classroom 
and inversely related to involvement in the juvenile 
justice system. It is also perceived that investment in 
prevention may be cost-effective. Although much 
research still needs to be done, communities and 
managed health care organizations eager to develop, 
maintain, and measure empirically supported 
preventive interventions are encouraged to use a risk 
and evidence-based framework developed by the 
National Mental Health Association (Mrazek, 1998). 

Some forms of primary prevention are so familiar 
that they are no longer thought of as mental health 
prevention activities, when, in fact, they are. For 
example, vaccination against measles prevents its 
neurobehavioral complications; safe sex practices and 
maternal screening prevent newborn infections such as 
syphilis and HIV, which also have neurobehavioral 
manifestations. Efforts to control alcohol use during 
pregnancy help prevent fetal alcohol syndrome 
(Stratton et al., 1996). All these conditions may 
produce mental disorders in children. 

This section describes several exemplary 
interventions that focus on enhancing mental health and 
primary prevention of behavior problems and mental 
health disorders. Prevention of a disorder or its 
recurrence or exacerbation is discussed together with 
that disorder in other sections of this chapter. 
Prevention strategies usually target high-risk infants. 



young children, adolescents, and/or their caregivers, 
addressing the risk factors described above. 

Project Head Start 

Project Head Start, though generally conceived of as an 
early childhood intervention program, is probably this 
country's best known prevention program. In 1965, 
when it was designed and first implemented in 2,500 
communities, Head Start's target population was 
economically disadvantaged preschool children. Its 
goal was to improve the social competence of these 
children through an 8-week comprehensive intervention 
that included a center-based component and a home 
visit by community aides, focusing on social, health, 
and education services (Karoly et al., 1998). A number 
of psychologists, most notably Jerome Bruner (1971), 
argued that children can be trained to think in a more 
logical way and that the development of logic is not 
entirely predetermined. Bruner' s views were very 
influential in launching early intervention programs 
such as Head Start. There is now ample evidence that, 
by providing an appropriately stimulating environment, 
significant advances in knowledge and reasoning 
ability can be achieved. 

The program has served over 15 million children 
and has cost $31 billion since its inception (General 
Accounting Office, 1997). It has changed in many ways 
in the intervening years, and there now is considerable 
program variation across localities (Zigler & Styfco, 
1993). Early evaluations of Head Start showed 
promising results in terms of higher IQ scores, but over 
the years many of the findings have met with criticism 
and skepticism. The reason is that there has been no 
national randomized controlled trial to evaluate the 
program as originally designed (Karoly et al., 1998). 

Repeated evaluations of Head Start programs that 
did not employ such a rigorous design (Berrento- 
Clement et al, 1984; Seitz et al., 1985; Lee et al., 1990; 
Yoshikawa, 1995) have shown that, although focused 
early education can improve test scores, the advantage 
is short-lived. The test scores of children of comparable 
ability who do not receive early childhood education 
quickly catch up with those who have been in Head 
Start programs (Lee et al., 1990). Yet there appear to be 



133 



Mental Health: A Report of the Surgeon General 



more enduring academic outcomes. A review of 36 
studies of Head Start and other early childhood 
programs found them to lower enrollment in special 
education and to enhance rates of high school 
graduation and promotion to the next grade level 
(Barnett, 1995). Head Start and other forms of early 
education offer arguably even more important benefits, 
which do not become apparent until children are older. 
The advantages are mainly social, rather than cognitive, 
and include better peer relations, less truancy, and less 
antisocial behavior (Berrento-Clement et al., 1984; 
Provence, 1985; Seitz et al., 1985; Webster-Stratton, 
1998; Weikart, 1998). Although important from a 
societal perspective, it is not known whether these very 
significant benefits are due to direct effects on the child 
or to the parent education programs that often accom- 
pany Head Start programs (Zigler & Styfco, 1993). 

Carolina Abecedarian Project 

The Carolina Abecedarian Project is an example of an 
early educational intervention for high-risk children 
that has been tested more rigorously than Head Start in 
well-designed, randomized, and controlled trials. It 
addresses the issue of the timing of the intervention, 
that is, when an intervention should begin and how 
long it should continue. Unlike Head Start, children 
were enrolled in this program at birth and remained in 
it for several years. 

In the Carolina Abecedarian Project, children who 
had been identified at birth as being at high risk for 
school failure on the basis of social and economic 
variables were enrolled in a child-centered prevention- 
oriented intervention program delivered in a day care 
setting from infancy to age 5 (Campbell & Ramey, 
1994'). The preschool intervention operated 8 hours a 
day for 50 weeks a year and included an infant 
curriculum to enhance development and parent 
activities. At elementary school age, a second 
intervention was provided: the children, who were then 
in kindergarten, received 15 home visits a year for 3 
years from a teacher who prepared a home program to 



' Also see Ramey et al., 1984; Ramey & Campbell, 1984; Horacek 
et al., 1987; Martin et al., 1990. 



supplement the school's basic curriculum. There were 
significant positive effects from the two-phase 
intervention on intellectual development and academic 
achievement, and these effects were maintained 
through age 12, which was 4 years after the 
intervention ended. 

Infant Health and Development Program 

The Infant Health and Development Program (IHDP) 
also began at birth and continued for several years and 
was also designed for low-birth-weight and premature 
infants (McCarton et al., 1997"^). The intervention was 
provided until the children reached 3 years of age. It 
included pediatric care, home visits, parent group 
meetings, and center-based schooling 5 days a week 
from 12 months of age to 3 years. At the end of the 
intervention, the group receiving it had significantly 
higher mean IQ scores than did the control group. Of 
note, although children's behavior problems were not 
targeted by the intervention, mothers of children in the 
intervention group reported significantly fewer 
behavior problems than those in the control group. 

Elmira Prenatal/Early Infancy Project 

The Elmira Prenatal/Early Infancy Project is an 
excellent example of a preventive intervention that 
targeted an at-risk population to prevent the onset of a 
series of health, social, and mental health problems in 
children and in their mothers (Olds et al., 1998 and 
previous years^). This study warrants special attention 
because of its positive and enduring findings, 
randomized, controlled design, cost-benefit analysis, 
and unusually long-term follow up of 15 years. The 
study began by focusing on pregnant women bearing 
their first child in a small, semirural county in upstate 
New York. The children of these women were 
considered high risk because of their mother's young 
maternal age, single-parent status, or low socio- 
economic level. There were four study groups to which 



^ Also see IHDP, 1990; Ramey et al., 1992; Brooks-Gunn et al., 
1994a, 1994b; Casey et al., 1994. 

' Also see Olds et al., 1986a, 1986b, 1988, 1993, 1994a, 1994b, 
1995, and 1997. 



134 



Children and Mental Health 



random assignment was made. The first group received 
developmental screening at ages 1 and 2; the second 
group received screening and free transportation to 
health care; the third group received screening, 
transportation, and nurse home visits once every 2 
weeks during pregnancy; and the fourth group received 
all of the above plus continued home visits by a nurse 
on a diminishing schedule until the infants were 24 
months of age. The intervention focused on parent 
education, enhancement of the women's informal 
support systems, and linkage with community services. 

Women in both groups receiving home visits from 
nurses had many positive behavioral outcomes 
compared with groups that received screening only or 
screening plus transportation. Among the women at 
highest risk for caregiver dysfunction, those who were 
visited by a nurse had fewer instances of verified child 
abuse and neglect during the first 2 years of their 
children's lives. They were observed in their homes to 
restrict and punish their children less frequently, and 
they provided more appropriate play materials. There 
were no differences between groups in the rates of new 
cases of child abuse and neglect or in the children's 
intellectual functioning in the period when the children 
were 25 to 48 months of age. However, nurse-visited 
children had fewer behavioral and parental coping 
problems (as noted in the physician record). Nurse- 
visited mothers were observed to be more involved 
with their children than were mothers in the 
comparison groups. 

A cost-benefit analysis estimated program costs 
(direct costs of nurse visitation, costs of services to 
which nurses linked families, and costs of 
transportation) and benefits (cost outcomes presumed 
to be affected by the program through improved 
maternal and child functioning, such as less use of Aid 
to Families With Dependent Children, Medicaid, food 
stamps, child protective services, and greater tax 
revenues generated by women's working). Taking a 
time point of 2 years after the program ended, the net 
cost of the program for the sample as a whole was 
$1,582 per family, but for low-income families, the cost 



of the program was recovered with a dividend of $180 
per family. 

Fifteen years after the birth of the index child (13 
years after termination of the intervention), women 
who were visited by nurses during pregnancy and 
infancy had significantly fewer subsequent preg- 
nancies, less use of welfare, fewer verified reports of 
abuse and neglect, fewer behavioral impairments due to 
use of alcohol and other drugs, and fewer arrests. Their 
children, now adolescents, reported fewer instances of 
running away, fewer arrests, fewer convictions and 
violations of probation, fewer lifetime sex partners, 
fewer cigarettes smoked per day, and fewer days having 
consumed alcohol in the last 6 months. The parents of 
these adolescents reported that their children had fewer 
behavioral problems related to use of alcohol and other 
drugs. 

Primary Mental Health Project 

The Primary Mental Health Project (PMHP) is a 42- 
year-old program for early detection and prevention of 
young children's school adjustment problems. PMHP 
currently operates in approximately 2,000 schools in 
700 school districts nationally and internationally. 
Seven states in the United States are implementing the 
program systematically, based on authorizing 
legislation and state appropriations. 

PMHP has four key elements: (1) a focus on 
primary grade children; (2) systematic use of brief 
objective screening measures for early identification of 
children in need; (3) use of carefully selected, trained, 
closely supervised nonprofessionals (called child 
associates) to establish a caring and trusting 
relationship with children; and (4) a changing role for 
the school professionals that features selection, 
training, and supervision of child associates, early 
systematic screening, and functioning as program 
coordinator, liaison, and consultant to parents, teachers 
and other school personnel. 

The PMHP model has been applied flexibly to 
diverse ethnic and sociodemographic groups in settings 
where help is most needed. Over 30 program evaluation 
studies, including several at the state level, underscore 



135 



Mental Health: A Report of the Surgeon General 



the program's efficacy (Co wen etal., 1996). Significant 
improvements were detected in children's grades, 
achievement test scores, and adjustment ratings by 
teachers and child associates. PMHP represents a 
successful mental health intervention that does not 
require highly trained and skilled mental health 
professionals. ' 

Other Prevention Programs and Strategies 

These and other prevention trials demonstrate that 
positive adaptation and social-emotional well-being in 
children and youth can be enhanced, and that risk 
factors for behavioral and emotional disorders can be 
reduced, by intervening in home, school, day care, and 
other settings. Programs have focused not only on 
mental health problems but also on other problem 
behaviors (Botvin et al., 1995; St. Lawrence et al, 
1995; Kellam & Anthony, 1998). 

Other prevention trials are showing similar 
benefits. For example, a large-scale, four-site school- 
and home-based prevention trial, known as FastTrack, 
has shown clear benefits in reducing behavior problems 
among high-risk children, as well as in reducing needs 
for and use of special education, which has substantial 
cost-effectiveness implications (Conduct Problems 
Prevention Research Group, 1999a, 1999b). Another 
trial is now under way to test the efficacy of a 
preventive intervention provided to adolescents whose 
parents are currently being treated for depression 
within a health maintenance organization (Clark et al., 
1998). Treatment of mood disorders also has potential 
effectiveness for the primary prevention of suicide, as 
explained in the later section on Depression and 
Suicide in Children and Adolescents. 

Overview of Mental Disorders in 
Children 

A consideration of developmental principles enhances 
understanding of mental illness in children and 
adolescents by reconciling the concept of mental 
disorder as a stable state or condition with the ongoing 



development of the child. According to these 
principles, a mental disorder results from the inter- 
action of a child and his or her environment. Thus, 
mental illness often does not lie within the child alone. 
Within the conceptual framework and language of 
integrative neuroscience, the mental disorder is an 
"emergent property" of the transaction with the 
environment. Proper assessment of a child's mood, 
thought, and behaviors demands a simultaneous 
consideration of nature and nurture, genes and 
environment, and biology and psychosocial influences. 
These relationships are reciprocal. The brain shapes 
behavior, and learning shapes the brain. 

Mental disorders must be considered within the 
context of the family and peers, school, home, and 
community. Taking the social-cultural environment into 
consideration is essential to understanding mental 
disorders in children and adolescents, as it is in adults. 
However, the changing nature of these environments, 
coupled with the progressively unfolding processes of 
brain development, makes the emphasis on context, as 
well as development, more complex and more central 
in child mental health (Jensen & Hoagwood, 1997). 

Thus, developmental psychopathology encourages 
consideration of the transactions between the individual 
and the social and physical environment at the same 
time that signs and symptoms of mental disorder are 
considered. Moreover, focusing on diagnostic labels 
alone provides too limited a view of mental disorders 
in children and adolescents. 

General Categories of Mental Disorders of 
Children 

Mental disorders with onset in childhood and 
adolescence are hsted in Table 3-2 as they appear in 
DSM-FV. These disorders fall into a number of broad 
categories, most of which apply not just to children but 
across the entire life span: anxiety disorders; attention- 
deficit and disruptive behavior disorders; autism and 
other pervasive developmental disorders; eating 
disorders (e.g., anorexia nervosa); elimination disorders 



136 



Children and Mental Health 



Table 3-2. Selected mental disorders of childhood and 
adolescence from the DSM-IV 



Anxiety Disorders 

Attention-Deficit and Disruptive Behavior Disorders 

Autism and Otiier Pervasive Developmental 
Disorders 

Eating Disorders 

Elimination Disorders 

Learning and Communication Disorders 

Mood Disorders (e.g., Depressive Disorders) 

Schizophrenia 

Tic Disorders 



(e.g., enuresis, encopresis); learning and communi- 
cation disorders; mood disorders (e.g., major depres- 
sive disorder, bipolar disorder); schizophrenia; and tic 
disorders (Tourette's disorder). Several of the more 
common childhood conditions are described below. 

Disorders of anxiety and mood are characterized by 
the repeated experience of intense internal or emotional 
distress over a period of months or years. Feelings 
associated with these conditions may be those of 
unreasonable fear and anxiety, lasting depression, low 
self-esteem, orworthlessness. Syndromes of depression 
and anxiety very commonly co-occur in children. The 
disorders in this broad group include separation anxiety 
disorder, generalized anxiety disorder, post-traumatic 
stress disorder, obsessive-compulsive disorder, major 
depressive disorder, dysthymia, and bipolar disorder 
(DSM-IV). 

Children who suffer from attention-deficit disorder, 
disruptive disorder, and oppositional defiant disorder 
may be inattentive, hyperactive, aggressive, and/or 
defiant; they may repeatedly defy the societal rules of 
the child' s own cultural group or disrupt a well-ordered 
environment such as a school classroom. 

Children with autism and other pervasive 
developmental disorders often suffer from disordered 
cognition or thinking and have difficulty understanding 
and using language, understanding the feelings of 
others, or, more generally, understanding the world 
around them. Such disorders are often associated with 



severe learning difficulties and impaired intelligence. 
The disorders in this category include the pervasive 
developmental disorders, autism, Asperger's disorder, 
and Rett's disorder (DSM-IV). 

It is not uncommon for a child to have more than 
one disorder or to have disorders from more than one of 
these groups. Thus, children with pervasive 
developmental disorders often suffer from ADHD. 
Children with a conduct disorder are often depressed, 
and the various anxiety disorders may co-occur with 
mood disorders. Learning disorders are common in all 
these conditions, as are alcohol and other substance use 
disorders (DSM-IV). 

Assessment and Diagnosis 

As with adults, assessment of the mental function of 
children has several important goals: to learn the 
unique functional characteristics of each individual 
(sometimes called formulation) and to diagnose signs 
and symptoms that suggest the presence of a mental 
disorder. Case formulation helps the clinician 
understand the child in the context of family and 
community. Diagnosis helps identify children who may 
have a mental disorder with an expected pattern of 
distress and limitation, course, and recovery. Both 
processes are useful in planning for treatment and 
supportive care. Both are helpful in developing a 
treatment plan. 

Even with the aid of widely used diagnostic 
classification systems such as DSM-IV (see Chapter 2), 
diagnosis and diagnostic classification present a greater 
challenge with children than with adults for several 
reasons. Children are often unable to verbalize thoughts 
and feelings. Clinicians by necessity become more 
reliant on parents, teachers, and other professionals, 
who may be unable to assess these mental processes in 
children. Children's normal development also presents 
an ever-changing backdrop that complicates clinical 
presentation. As previously noted, some behaviors may 
be quite normal at one age but suggest mental illness at 
another age. Finally, the criteria for diagnosing most 
mental disorders in children are derived from those for 
adults, even though relatively little research attention 
has been paid to the validity of these criteria in 



137 



Mental Health: A Report of the Surgeon General 



children. Expression, manifestation, and course of a 
disorder in children might be very different from those 
in adults. The boundaries between normal and 
abnormal are less distinct and those between one 
diagnosis and another are fluid. 

Thus, the field of childhood mental health 
historically downplayed diagnosis. This trend began to 
change in the 1980s, in part as a result of developing 
practice guidelines and tougher reimbursement 
standards (Lonigan et al., 1998) and more appropriate 
diagnostic categories and criteria (DSM HI, ni-R, and 
rV). The body of accumulated research on treatment 
and services referred to throughout this chapter reflects 
the past emphasis on the efficacy of treatments, 
sometimes with and sometimes independently of 
diagnosis. 

Most disorders are diagnosed by their manifesta- 
tions, that is, by symptoms and signs, as well as 
functional impairment (see Chapter 2). A diagnosis is 
made when the combination and intensity of symptoms 
and signs meet the criteria for a disorder listed in DSM- 
IV. However, diagnosis of childhood mental disorders, 
as noted earlier, is rarely an easy task. Many of the 
symptoms, such as outbursts of aggression, difficulty in 
paying attention, fearfulness or shyness, difficulties in 
understanding language, food fads, or distress of a child 
when habitual behaviors are interfered with, are normal 
in young children and may occur sporadically 
throughout childhood. Well-trained clinicians 
overcome this problem by determining whether a given 
symptom is occurring with an unexpected frequency, 
lasting for an unexpected length of time, or is occurring 
at an unexpected point in development. Clinicians with 
less experience may either overdiagnose normal 
behavior as a disorder or radss a diagnosis by failing to 
recognize abnormal behavior. Inaccurate diagnoses are 
more likely in children with mild forms of a disorder. 

Evaluation Process 

When conducted by a mental health professional, the 
evaluation process usually consists of gathering 
information from several sources: the child, parents. 



teachers, pediatricians, and hospital records. The 
mental health professional also makes observations of 
the child's or teenager's behavior and patterns of 
speech. Very often, additional testing is requested to 
assess the child's or youth's intelligence and learning 
abilities. Information about symptoms can be obtained 
more reliably by direct questioning (Gittelman-Klein, 
1978; Gittelman, 1985). 

A full evaluation may take several hours. By that 
time, the professional should have a good 
understanding of how the child is functioning at home, 
at school, and in society and some understanding of the 
family's characteristics. With this information, the 
child or adolescent psychiatrist, clinical psychologist, 
or social worker can suggest further investigations and, 
if needed, initiate treatment of the child and provide 
counseling to parents and teachers on how to best assist 
the child or teenager to overcome problems. 

There is a dearth of child psychiatrists, appro- 
priately trained clinical child psychologists, or social 
workers (Thomas & Holzer, 1999). Furthermore, many 
barriers remain that prevent children, teenagers, and 
their parents from seeking help from the small number 
of specially trained professionals who are available. 
This places a burden on pediatricians, family 
physicians, and other gatekeepers (such as school 
counselors and primary child care workers) to identify 
children for referral and treatment decisions. These 
gatekeepers are unlikely to have the time and 
specialized training to do an evaluation requiring 
several hours. Their responsibility often is to "triage" 
cases, that is, refer children who need further 
evaluation to specialists. Many, however, are involved 
in treating children and adolescents. They may be 
greatly aided by various diagnostic aids such as brief 
questionnaires that can be completed in the waiting 
room of the pediatrician, the school counseling office, 
or some other community setting. Ideally, these 
screening questionnaires would be accompanied by a 
clear guide on interpreting results and identifying what 
kind of score or behavior would normally indicate a 
need for referral to a professional. 



138 



Some of the questionnaires that specifically address 
mood disorders are shown in Figure 3-1. Other ques- 
tionnaires, such as the Adolescent Antisocial Self- 
Report Behavior Checklist (Kulik et al., 1968), the 
Eyberg Child Behavior Liventory (Eyberg & Robinson, 
1983), and the Family Interaction Coding Pattern 
(Patterson, 1982), assess antisocial behavior. Adults 
and teachers can use instruments such as the Child 
Behavior Checklist (Achenbach & Edelbrock, 1983) to 
assess a relatively full range of behavioral and 
emotional symptoms and disorders from the perspective 
of adult informants. The Minnesota Multiphasic 
Personality Inventory-2 (MMPI-2; Hathaway & 
McKinley, 1989) and the Millon Adolescent Personal- 



Children and Mental Health 

Treatment Strategies 

Children and adolescents receive most of the traditional 
treatments described in Chapter 2, particularly psycho- 
social treatments, such as psychotherapies, and various 
medications. Specific psychosocial and pharma- 
cological treatment approaches are described in 
subsequent sections on specific mental disorders. Much 
of the research, however, has been conducted on adults, 
with results extrapolated to children. Some of the 
treatments, such as interactive or play therapy with 
young children, are unique to clinical work with this 
group, while others, such as individual psychotherapy 
with adolescents, are similar to clinical work with 
adults. Many of the treatment interventions have been 



Figure 3-1. Questionnaires used to assess 


childhood mood disorders 


Title 




Source 


The Children's Depression Inventory 




Kovacs, 1985 


(GDI) 






Beck Depression Inventory 




Beck, Ward, Mendelson, Mock, & Erbaugh, 1961 


(BDI) 






Reynolds Adolescent Depression Scale 




Reynolds, 1986 


(PADS) 






Children's Depression Scale 




Tisher & Lang, 1983 


(CDS) 






Center for Epidemiological Studies of Depression 


Radloff, 1977 


(CES-D) 






Kandel Depression Scale 




Kandel & Davies, 1982 


(KDS) 






Zung Self-Rating Depression Scale 




Zung, 1965 


(SDS) 






Diagnostic Interview Schedule for Children 




Shaffers Fisher, 1998 


(DISC) 







ity Inventory (MAPI) (Millon et al, 1982) 
questionnaires may be used with adolescents to assess 
normal and abnormal personality function. 

The advent of highly structured, computer-driven 
assessment tools, such as the NIMH Diagnostic 
Interview Schedule for Children, which comes in a 
spoken version that can be given through headphones 
to children and/or their parents (Shaffer et al., 1996a), 
promises to greatly improve the ability of professionals 
outside of the mental health field to obtain robust 
diagnostic information, which can guide them in 
decisions about further referral or treatment. 



"packaged" together in particular arrangements for 
delivery in specific clinical settings. 

More attention is being paid to the value of 
multimodal therapies, that is, the combination of 
pharmacological and psychosocial therapies. While 
research is limited, multimodal studies have shown 
benefits for treatment of ADHD (see later section), 
anxiety (Kearney & Silverman, 1998), and depression. 
Tempering the value of psychotherapy as well as 
pharmacotherapy, which is discussed below, is that the 
efficacy of these therapies in the research setting is 
greater than that in the real world. The problem of the 



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Mental Health: A Report of the Surgeon General 



gap between research and clinical practice is discussed 
in greater depth elsewhere in this chapter and in 
Chapter 2. 

Psychotherapy 

The major types of psychotherapy for children are 
supportive, psychodynamic, cognitive-behavioral, inter- 
personal, and family systemic. With the exception of 
the latter, these therapies originally were developed for 
adults and then tailored for use in children. 

Most psychotherapies are deemed effective for 
children and adolescents because they improve more 
than with no treatment, as discussed later in this 
chapter under Treatment Interventions (Casey & 
Herman, 1985; Hazelrigg et al., 1987; Weisz et al, 
1987; Kazdin et al., 1990; Baer & Nietzel, 1991; 
Grossman & Hughes, 1992;Shadishetal., 1993; Weisz 
& Weiss, 1993; Weisz et al, 1995). But despite this 
strong body of research on children comparing 
treatment with no treatment, far less attention has been 
paid to, and guidance provided about, the efficacy of a 
given psychotherapy for a specific diagnosis (Lonigan 
et al., 1998). In other words, it is not clear which 
therapies are best for which conditions. The American 
Psychological Association sought to rectify this 
problem by convening two task forces, the second of 
which exhaustively reviewed the professional literature 
to evaluate the strength of the evidence for treating 
individual disorders in children. The second task force 
refined two sets of criteria against which to evaluate the 
evidence: the first, and more rigorous, set of criteria 
was for Weil-Established Psychosocial Interventions, 
while the other was for Probably Efficacious Psycho- 
social Interventions (Lonigan et al., 1998). The 
findings of the task force's comprehensive evaluation 
were published, disorder by disorder, in an entire issue 
of the Journal of Clinical Child Psychology in June 
1998. While findings relating to individual disorders 
are presented in the next section of this chapter, this 
was the overarching conclusion: ". . . the majority of 
these [psychosocial] interventions do not meet criteria 
for the highest level of empirical support, the well- 
established criteria" (Lonigan et al., 1998). The 
problem, according to these authors, is that too few 



well-controlled studies have been performed for each 
disorder. To meet the criteria for a Well-Established 
Psychosocial Intervention, there must be at least two 
well-conducted group-design studies conducted by 
different teams of researchers, among other criteria.'' 
Hereafter, these criteria are referred to as the American 
Psychological Association Task Force Criteria. 

Some other general points are warranted about the 
value of psychotherapies for children. Psychotherapies 
are especially important alternatives for those children 
who are unable to tolerate, or whose parents prefer 
them not to take, medications. They also are important 
for conditions for which there are no medications with 
well-documented efficacy. They also are pivotal for 
families under stress from a child's mental disorder. 
Therapies can serve to reduce stress in parents and 
siblings and teach parents strategies for managing 
symptoms of the mental disorder in their child (see 
later sections on Disruptive Disorders and Home-Based 
Services). 

Psychopharmacology 

Dramatic increases have occurred over the past decade 
in the use of pharmacological therapies for children and 
adolescents with mental disorders, but research has 
lagged behind the surge in their use (Jensen et al., 
1999). Our gaps in knowledge span three areas in 
particular. First, for most prescribed medications, there 
are no studies of safety and efficacy for children and 
adolescents. This is true for medications for mental 
disorders as well as for somatic disorders. Depending 
on the specific medication, evidence may be lacking for 
short-term, or most commonly, for long-term safety and 
efficacy. The problem is even more pronounced with 
newer medications, most of which have been 
introduced into the market for adults. Only in the case 
of psychostimulants for ADHD is there an adequate 
body of research on their safety and efficacy in children 
and adolescents, albeit short-term information only 
(Greenhill et al., 1998) (see later section on ADHD). 
Second, there is often limited information about 
pharmacokinetics, that is, drug concentrations in body 

** The criteria are listed in Chapter 1 . 



( 



140 



Children and Mental Health 



fluids and tissues over time (Clein & Riddle, 1996). 
Most of what is known about pharmacokinetics comes 
from studies of adults. But pediatric pharmacokinetic 
studies are crucial to identifying the appropriate dose 
and dose frequency for children of different ages and 
body sizes. Third, the combined effectiveness of 
pharmacological and psychosocial treatments, that is, 
multimodal treatments, is seldom studied. Multimodal 
treatments have the potential to yield dose reductions 
in pharmacological treatments, thereby improving the 
side-effect profile, parental acceptance, and patient 
compliance. 

The dearth of research on children and adolescents 
has allowed for widespread "off-label" use of 
medications. This means that, for this population, 
physicians who are prescribing a given drug do not 
have the benefit of research and drug labeling 
information developed by the sponsor and approved by 
the Food and Drug Administration (FDA). Under U.S. 
food and drug law, a drug is approved by the FDA only 
for a defined population. Yet after its approval and 
market availability, physicians are at liberty to 
prescribe it for anyone, even though the sponsor only is 
allowed to market the drug for the approved population 
(which typically is adults) (FDA, 1998). Fortunately, 
there is a large body of clinical experience with 
children and adolescents to guide prescribing practices, 
despite few controlled studies (Green, 1996). 

There are several reasons for the paucity of 
research on medications for children and adolescents. 
One is greater caution on the part of both the medical 
profession and parents to experiment with children or 
to prescribe drugs with potentially serious side effects. 
Another reason is the need for compliance with dosing 
requirements of the clinical trial protocol. When 
children are research subjects, enforcing compliance is 
generally perceived to be more difficult. Researchers 
must rely on parents to assess the degree of 
compliance. A final reason is the cost of research. Once 
drugs have reached the market for adults, pharmaceuti- 
cal companies have fewer financial incentives to 
conduct expensive and methodologically demanding 
studies with children, to whom drugs may be given 



through off-label prescribing. The problem has been 
significant enough to have galvanized Congress into 
passing legislation, the FDA Modernization Act of 
1997, to create financial incentives for drug sponsors to 
conduct research with pediatric subjects [FDA, 1999 
Title 21 use 505 A(g)]. The FDA Modernization Act 
may help alleviate this problem, but it is too early to 
tell. 

Despite the relative lack of information concerning 
safety and efficacy of psychotropic agents in children, 
six scientific reviews have been completed recently; 
these reviews comprehensively surveyed all available 
published research concerning the safety and efficacy 
of psychotropic medication, focusing on six general 
classes of medication: the psychostimulants (Greenhil) 
et al., 1998), the mood stabilizers and antimanic agents 
(Ryan et al., 1999), the selective serotonin reuptake 
inhibitors (SSRIs) (Emslie et al., 1999), antidepressants 
(Geller et al., 1998), antipsychotic agents (Campbell et 
al., 1999), and other miscellaneous agents (Riddle et 
al., 1998). 

Review of this comprehensive body of research 
evidence indicates strong support for the safety and 
efficacy of several classes of agents for several 
conditions, specifically, SSRIs for childhood/ 
adolescent obsessive-compulsive disorder, and the 
psychostimulants for ADHD. For many other disorders 
and medications, however, information from rigorously 
controlled trials is sparse or altogether absent (see 
Figure 3-2). Further, only in the area of ADHD is in- 
formation now emerging on longer term safety and 
efficacy, as well as on the merits of combining 
psychopharmacologic and psychotherapeutic 
treatments. 

Given the inadequacy of efficacy data for most 
nonstimulant psychotropics, studies are needed for the 
majority of agents. However, efficacy data appear to be 
most urgently needed for SSRIs, mood stabilizers, and 
novel antipsychotics, since the level of usage of these 
medications appears to be highest among the growing 
list of psychotropic medications used in youth (Fisher 
& Fisher, 1996). In contrast to adult psycho- 
pharmacology that is focusing on differential efficacy 
and speed of onset of these categories of psychotropics. 



141 



Mental Health: A Report of the Surgeon General 



Figure 3-2. Grading the Level of Evidence for Efficacy of Psychiotropic Drugs in Children 



Level of Supporting Data 



Estimated 

Frequency 

of Use 



1 Short-Term | Long-Term | Short-Term | Long-Term | 
Category Indication | Efficacy | Efficacy | Safety | Safety | Rank 


Stimulants ADHD 1 A | B | A | A | 1 


Selective Serotonin Major depression 1 B 1 C 1 A 1 C 1 
Reuptake Inhibitors OCD | A | C | A | C | 2 
Anxiety disorders C C C ^1 


Central Adrenergic Tourette syndrome | B | C | B | C | 
Agonists ADHD C C C i C i ^ 


Valproate and Bipolar disorders | C | C | A | A | 
Carbamazepine Aggressive conduct | C | C A | A 


Tricyclic Major depression | C | C | B | B | 
Antidepressants ADHD B C B B 


Benzodiazepines Anxiety disorders | | C | C | C | 6 


Antipsychotics Childhood schizophrenia 1 1 1 1 1 

and psychoses | B | | C | B | 7 
Tourette syndrome | A B B 


Lithium Bipolar disorders | B | C | B | C | g 
Aggressive conduct | B | | | C | 



Key: A = > 2 randomized controlled trials (RCTs). 
B = At least 1 ROT. 
C = Clinical opinion, case reports, and uncontrolled trials. 

Source: Jensen et al., 1999 



pediatric psychopharmacology needs basic studies of 
efficacy. 

Additional information on specific medication 
treatment is presented in the succeeding sections, 
providing more detailed discussion of particular 
disorders. Indepth information is presented on two 
disorders where a great deal of research has been done, 
namely, ADHD and major depressive disorder, 
followed by briefer discussions of other childhood 
mental disorders. 

Attention-Deficit/Hyperactivity 
Disorder 

As its name implies, attention-deficit/hyperactivity 
disorder (ADHD) is characterized by two distinct sets 
of symptoms: inattention and hyperactivity-impulsivity 



(see Table 3-3). Although these problems usually occur 
together, one may be present without the other to 
qualify for a diagnosis (DSM-IV). Inattention or 
attention deficit may not become apparent until a child 
enters the challenging environment of elementary 
school. Such children then have difficulty paying 
attention to details and are easily distracted by other 
events that are occurring at the same time; they find it 
difficult and unpleasant to finish their schoolwork; they 
put off anything that requires a sustained mental effort; 
they are prone to make careless mistakes, and are 
disorganized, losing their school books and assign- 
ments; they appear not to listen when spoken to and 
often fail to follow through on tasks (DSM-IV; Waslick 
& Greenhill, 1997). 



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Children and Mental Health 
Table 3-3. DSM-IV criteria for Attention-Deficit/Hyperactivity Disorder 



A. Either (1) or (2): 

(1) six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that 
is maladaptive and inconsistent with developmental level: 

Inattention 

(a) often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other 
activities 

(b) often has difficulty sustaining attention in tasks or play activities 

(c) often does not seem to listen when spoken to directly 

(d) often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the 
workplace (not due to oppositional behavior or failure to understand instructions) 

(e) often has difficulty organizing tasks and activities 

(f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as 
schoolwork or homework) 

(g) often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or 
tools) 

(h) Is often easily distracted by extraneous stimuli 
(i) is often forgetful in daily activities 

(2) six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months 
to a degree that is maladaptive and inconsistent with developmental level: 

Hyperactivity 

(a) often fidgets with hands or feet or squirms in seat 

(b) often leaves seat in classroom or in other situations in which remaining seated is expected 

(c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, 
may be limited to subjective feelings of restlessness) 

(d) often has difficulty playing or engaging in leisure activities quietly 

(e) is often "on the go" or often acts as if "driven by a motor" 

(f) often talks excessively 

Impulsivity 

(g) often blurts out answers before questions have been completed 
(h) often has difficulty awaiting turn 

(i) often interrupts or intrudes on others (e.g., butts into conversations or games) 

B. Some hyperactive-impulsive or inattentive symptoms that cause impairment were present before age 7 years. 

C. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home). 

D. There must be clear evidence of clinically significant impairment in social, academic, or occupational 
functioning. 

E. The symptoms do not occur exclusively during the course of a pervasive developmental disorder, 
schizophrenia, or other psychotic disorder and are not better accounted for by another mental disorder 

(e.g., mood disorder, anxiety disorder, dissociative disorder, or a personality disorder). 



143 



Mental Health: A Report of the Surgeon General 

The symptoms of hyperactivity may be apparent in 
very young preschoolers and are nearly always present 
before the age of 7 (Halperin et al., 1993; Waslick & 
Greenhill, 1997). Such symptoms include fidgeting, 
squirming around when seated, and having to get up 
frequently to walk or run around. Hyperactive children 
have difficulty playing quietly, and they may talk 
excessively. They often behave in an inappropriate and 
uninhibited way, blurting out answers in class before 
the teacher's question has been completed, not waiting 
their turn, and interrupting often or intruding on others' 
conversations or games (Waslick & Greenhill, 1997). 

Many of these symptoms occur from time to time 
in normal children. However, in children with ADHD 
they occur very frequently and in several settings, at 
home and at school, or when visiting with friends, and 
they interfere with the child's functioning. Children 
suffering from ADHD may perform poorly at school; 
they may be unpopular with their peers, if other 
children perceive them as being unusual or a nuisance; 
and their behavior can present significant challenges 
for parents, leading some to be overly harsh (DSM-IV). 

Inattention tends to persist through childhood and 
adolescence into adulthood, while the symptoms of 
motor hyperactivity and impulsivity tend to diminish 
with age. Many children with ADHD develop learning 
difficulties that may not improve with treatment 
(Mannuzza et al., 1993). Hyperactive behavior is often 
associated with the development of other disruptive 
disorders, particularly conduct and oppositional-defiant 
disorder (see Disruptive Disorders). The reason for the 
relationship is not known. Some believe that the 
impulsivity and heedlessness associated with ADHD 
interfere with social learning or with close social bonds 
with parents in a way that predisposes to the 
development of behavior disorders (Barkley, 1998). 

Even though a great many children with this 
disorder ultimately adjust (Mannuzza et al., 1998), 
some — especially those with an associated conduct or 
oppositional-defiant disorder — are more likely to drop 
out of school and fare more poorly in their later careers 
than children without ADHD. As they grow older. 



some teens who have had severe ADHD since middle 
childhood experience periods of anxiety or depression. 
This seems to be especially common in children whose 
predominant symptom is inattention (Morgan et al., 
1996). Excellent reviews of ADHD can be found in 
DSM-IV and other sources.^ 

Prevalence 

ADHD, which is the most commonly diagnosed 
behavioral disorder of childhood, occurs in 3 to 5 
percent of school-age children in a 6-month period 
(Anderson et al., 1987; Bird et al., 1988; Esser et al., 
1990; Pelham et al., 1992; Shaffer et al, 1996c; 
Wolraich et al., 1996). Pediatricians report that 
approximately 4 percent of their patients have ADHD 
(Wolraich et al., 1990), but in practice the diagnosis is 
often made in children who meet some, but not all, of 
the criteria recommended in DSM-IV (Wolraich et al., 
1990) (see also Treatment later in this section). Boys 
are four times more likely to have the illness than girls 
are (Ross & Ross, 1982). The disorder is found in all 
cultures, although prevalences differ; differences are 
thought to stem more from differences in diagnostic 
criteria than from differences in presentation 
(DSM-IV). 

Causes 

The exact etiology of ADHD is unknown, although 
neurotransmitter deficits, genetics, and perinatal 
complications have been implicated. In the early post- 
World War n years, a number of pediatricians, 
neurologists, and child psychiatrists noted that brain- 
damaged children were often hyperactive (Strauss & 
Lehtinen, 1947; Eisenberg, 1957; Laufer & Denhoff, 
1957). These observations led to the diagnostic concept 
of "minimal brain damage" (Wender, 1 97 1 ), which was 
thought to be characterized by hyperactivity, inat- 
tention, learning difficulties, and a wide variety of 
behavior problems. However, large epidemiological 
studies (Rutter & Quinton, 1977) of grossly brain- 
damaged children with cerebral palsy, epilepsy, and so 



' Taylor, 1994; Cantwell, 1996; Waslick & Greenhill, 1997; 
Barkley, 1998; and NIH Consensus Statement 1 10, 1998. 



144 



Children and Mental Health 



forth, did not find an excess of hyperactivity, and more 
recent imaging studies have found no evidence of gross 
brain damage in children with ADHD (Swanson et al., 
1998). The past view that ADHD is a form of minimal 
brain damage has therefore been abandoned by experts. 
Many brain-damaged children are, if anything, 
significantly underactive. 

In the late 1970s, it was postulated that the core 
problem in hyperkinetic children was one of inattention 
(Douglas & Peters, 1979). This view led, in 1980, to 
the adoption, in the official DSM-III (American 
Psychiatric Association, 1980) nomenclature, of the 
new diagnostic label attention-deficit disorder. 

Because the symptoms of ADHD respond well to 
treatment with stimulants, and because stimulants 
increase the availability of the neurotransmitter 
dopamine, the "dopamine hypothesis" has gained a 
wide following. The dopamine hypothesis posits that 
ADHD is due to inadequate availabihty of dopamine in 
the central nervous system. The neurotransmitter 
dopamine plays a key role in initiating purposive 
movement, increasing motivation and alertness, 
reducing appetite, and inducing insomnia, effects that 
are often seen when a child responds well to 
methylphenidate. The dopamine hypothesis has thus 
driven much of the recent research into the causes of 
ADHD. 

The fact that ADHD runs in families suggests that 
inheritance is an important risk factor. Between 10 and 
35 percent of children with ADHD have a first-degree 
relative with past or present ADHD. Approximately 
one-half of parents who had ADHD have a child with 
the disorder (Biederman et al., 1995). Over the past 
decade, a large number of twin studies have shown that, 
when ADHD is present in one twin, it is significantly 
more likely also to be present in an identical twin than 
in a fraternal twin (Goodman & Stevenson, 1989). 
These findings have led geneticists to estimate that 
genes are important in a high proportion of children 
with ADHD. 

Research to pinpoint abnormal genes is honing in 
on two genes: a dopamine -receptor (DRD) gene on 



chromosome 11 and the dopamine-transporter gene 
(DATl) on chromosome 5 (Cook et al, 1995; Smalley 
et al., 1998). Several studies have found evidence that 
children with ADHD have genetic variations in one of 
the dopamine-receptor genes (DRD4), although the 
largest of these studies suggests that the presence of 
such a variation is associated with only a modest 
increase in the risk of developing ADHD (Smalley et 
al., 1998). Several other studies have found evidence 
for abnormalities of the dopamine-transporter gene 
(DATl) in children with very severe forms of ADHD 
(Cook et al., 1995; Gill et al., 1997; Waldman et al., 
1998). 

Yet for most children with ADHD, the overall 
effects of these gene abnormalities appear small, 
suggesting that nongenetic factors also are important. 
Although none of the many imaging studies have found 
evidence of gross brain damage, some investigators 
have suggested that exposure to toxins, such as lead, or 
episodes of oxygen deprivation for the fetus, as may 
occur during some complications of pregnancy, may 
adversely affect dopamine-rich areas of the brain. 
These theories support observations that hyperactivity 
and inattention are more common in children whose 
mothers smoked during pregnancy (Nichols & Chen, 
1981), in children who have been exposed to high 
quantities of lead (Needleman et al., 1990), and in 
children who had a lack of oxygen in the neonatal 
period (Whittaker et al., 1997). 

Some investigators have noted that the parents of 
hyperactive children are often overintrusive and 
overcontrolUng (Carlson et al., 1995). It has therefore 
been suggested that such parental behavior is another 
possible risk factor for ADHD. However, others have 
noted that, when children are treated with 
methylphenidate, there is a reduction in parental 
negativity and intrusiveness. This suggests that the 
observed overintrusive and overcontroUing behavior of 
the parent is a response to the child's behavior rather 
than the cause (Barkley et al., 1985). 



145 



Mental Health: A Report of the Surgeon General 



Treatment 

The American Academy of Child and Adolescent 
Psychiatry (AACAP) published "practice parameters" 
(i.e., guidelines for clinical practice) on the diagnosis 
and treatment of ADHD. The AACAP parameters 
include an extensive literature review, detailed 
descriptions of the clinical presentation of the disorder, 
and recommendations for treatment. The practice 
parameters state that "the cornerstones of treatment are 
support and education of parents, appropriate school 
placement, and pharmacology" (AACAP, 1991). These 
practice parameters evolved out of research relating to 
two major types of treatment: pharmacological 
treatment and psychosocial treatment, particularly 
behavioral modification, as well as multimodal 
treatment, the combination of psychosocial and 
pharmacological treatments. 

Pharmacological Treatment 

Psychostimulants 

Pharmacological treatment with psychostimulants is the 
most widely studied treatment for ADHD. Stimulant 
treatment has been used for childhood behavioral 
disorders since the 1930s (Bradley, 1937). 
Psychostimulants are highly effective for 75 to 90 
percent of children with ADHD. At least four separate 
psychostimulant medications consistently reduce the 
core features of ADHD in literally hundreds of 
randomized controlled trials: methylphenidate, dextro- 
amphetamine, pemoline, and a mixture of amphetamine 
salts (Spencer et al., 1995; Greenhill, 1998a, 1998b; 
Greenhill et al., 1998). 

These medications are metabolized, leave the body 
fairly quickly, and work for 1 to 4 hours. Administra- 
tion is timed to meet the child's school schedule, to 
help the child pay attention and meet his or her 
academic demands, and to mitigate side effects. These 
medications have their greatest effects on symptoms of 
hyperactivity, impulsivity, and inattention and the 
associated features of defiance, aggression, and 
oppositionality. They also improve classroom 
performance and behavior and promote increased 
interaction with teachers, parents, and peers. Small 
effects were found on learning and school achievement 



(see reviews by Barkley, 1990; Pelham, 1993; Swanson 
et al.,1993, 1995b; Greenhill et al., 1998; Cantwell, 
1996a; Spencer et al., 1996.) However, psychostimu- 
lants do not appear to achieve long-term changes in 
outcomes such as peer relationships, social or academic 
skills, or school achievement (Pelham et al., 1998). 

Children who do not respond to one stimulant may 
respond to another (Elia et al., 1991; Eha & Rapoport, ^ 
1991). Children should be reevaluated without the 
medication to see if stimulant treatment is still 
indicated. Many families choose to have their child 
take a "drug holiday" on weekends and vacations to 
reduce overall exposure, but the utility of this strategy 
has not been demonstrated (AACAP, 1991). 

Dosing 

Stimulants are usually started at a low dose and 
adjusted weekly (AACAP, 1991). A recent study 
demonstrated that the practice of dosing 
methylphenidate on the basis of body weight fails to 
predict the optimal dose of medication (Rapport & 
Denney, 1997). One of the goals of the recently 
completed NIMH Multimodal Treatment Study of 
ADHD (described more fully below) was to develop 
medication strategies to guide "best dose," dose 
changes, management of side effects, and integration 
with other treatments (Greenhill et al., 1996). 

Side Effects 

Common stimulant side effects include insomnia, 
decreased appetite, stomach aches, headaches, and 
jitteriness. Some children may develop tics, but a recent 
study suggests that they disappear with continued 
treatment (Gadow et al., 1995). Rebound activation 
(i.e., a sudden increase in attention deficit and 
hyperactivity) has been noted anecdotally after the 
child's last dose of medication wears off (Johnston et 
al., 1988). Most of the side effects are mild, recede over 
time, and respond to dose changes. Children rarely 
experience cognitive impairment, which, if it does 
occur, can be resolved with reduction or cessation of 
the drug (Cantwell, 1996). A few cases of psychosis 
have been reported. Pemoline has been associated with 
hepatotoxicity, so monitoring of liver function is 



146 



Children and Mental Health 



necessary. Two studies have shown no long-term 
effects of stimulants on later height or weight (Klein & 
Mannuzza, 1988; Vincent et al., 1990). Nonetheless, 
regular precautionary monitoring of weight and height 
for children on stimulants is recommended. 

Other Medications 

For children with ADHD who do not respond to 
stimulants (10 to 30 percent) or cannot tolerate the side 
effects, there are other useful medications. The 
antidepressant bupropion has been found to be superior 
to placebo, although the response is not as strong as 
that found with stimulants (Cantwell, 1 998). Bupropion 
can also be used as an adjunct to augment stimulant 
treatment. Well-controlled trials have shown tricyclic 
antidepressants to be superior to placebo but less 
effective than stimulants (Elia et al., 1991; Elia & 
Rapoport, 1991). Reports of sudden death of a few 
children in the early 1990s on the tricyclic compound 
desipramine led to great caution with the use of 
tricyclics in children (Riddle et al., 1991). 

Considerable controversy surrounds the use of 
central alpha-adrenergic blocking drugs, such as 
clonidine and guanfacine, to treat ADHD. There is 
some evidence that clonidine is effective for ADHD 
when it occurs with a tic disorder (Hunt, 1987; Hunt et 
al., 1990, 1995). Caution is warranted in view of the 
four cases of sudden death that have been reported in 
children taking methylphenidate and clonidine together 
and of a number of reports of nonfatal cardiac side 
effects in children taking clonidine alone or in 
combination (Swanson et al., 1995a). 

Neuroleptics have been found to be occasionally 
effective (Green, 1995), yet the risk of movements 
disorders, such as tardive dyskinesia, makes their use 
problematic. Lithium, fenfluramine, or benzodiazapines 
have not been found to be effective treatments for 
ADHD (Cantwell, 1996a; Green, 1995), nor have 
SSRIs, such as fluoxetine (Goldman et al., 1998). 
Furthermore, more than 20 studies have shown that 
dietary manipulation (e.g., the Feingold diet) is not 
efficacious (Mattes & Gittelman, 198 1), and controlled 
studies failed to demonstrate that sugar exacerbates the 



symptoms of children with ADHD (Milich & Pelham, 
1986). 

Psychosocial Treatment 

Lnportant options for the management of ADHD are 
psychosocial treatments, particularly in the form of 
training in behavioral techniques for parents and 
teachers. Behavioral techniques, which are described 
more fully below, typically employ "time-out," point 
systems and contingent attention (adults reinforcing 
appropriate behavior by paying attention to it). 
Psychosocial treatments are useful for the child who 
does not respond to medication at all or for whom the 
therapeutic benefits of the medication have worn off 
and for the child who responds only partially to 
medication or cannot tolerate medication. In addition, 
some families express a strong preference not to use 
medication. Even children who are receiving 
medication may continue to have residual ADHD 
symptoms or symptoms from other disorders, such as 
oppositional defiant disorder or depression, which 
make specialized child management skills necessary 
and helpful (see next section, Multimodal Treatments). 
Furthermore, children with ADHD can present a 
challenge that puts significant stress on the family. 
Skills training for parents can help reduce this stress on 
parents and sibUngs. 

Behavioral Approaches 

The main psychosocial treatments for ADHD are 
behavioral training for parent and teacher, as well as 
systematic programs of contingency management (this 
behavioral technique is described in more detail in the 
Treatment section later in this chapter). Of these 
options, systematic programs of intensive contingency 
management conducted in specialized classrooms or 
summer camps with the setting controlled by highly 
trained individuals is the most effective (Abramowitz 
et al., 1992; Carlson et al., 1992; Pelham & Hoza, 
1996). The efficacy of behavioral training of teachers 
is well-established, while the evidence for parent 
training is less solid, according to the criteria, noted 
earlier, promulgated by the American Psychological 



147 



Mental Health: A Report of the Surgeon General 



Association Task Force (Pelham et al., 1998). There is, 
however, indirect support for the effectiveness of 
parent training in the Uterature, demonstrating the 
efficacy of parent training for children with 
oppositional defiant disorder who share many 
characteristics with children who have ADHD (see 
section on Disruptive Disorders). 

A number of studies have compared parent training 
(Gittelman et al., 1980; Firestone et al., 1986; Horn et 
al., 1987, 1990, 1991; Pelham et al., 1988) or school- 
based behavioral modification (Gittelman et al., 1980; 
Pelham et al., 1988) with the use of stimulants. Most of 
the studies are of outpatient behavioral therapy 
programs in which parents meet in groups and are 
taught behavioral techniques such as time out, point 
systems, and contingent attention. Teachers are taught 
similar classroom strategies, as well as the use of a 
daily report card for parents that evaluates the child's 
in-school behavior. The improvements in the symptoms 
of ADHD achieved with psychosocial treatments are 
not as large as those found with psychostimulants 
(Pelham et al., 1998). Behavioral interventions tend to 
improve targeted behaviors or skills but are not as 
helpful in reducing the core symptoms of inattention, 
hyperactivity, or impulsivity. Questions remain about 
the effectiveness of these treatments in other settings. 
To be fully effective, treatments for ADHD need to be 
conducted across settings (school, home, community) 
and by different people (e.g., parents, teachers, 
therapists) — a consistency and comprehensiveness that 
can be hard to achieve. 

Cognitive-Behavioral Therapy 
Cognitive-behavioral therapy (CBT), primarily training 
in problem solving and social skills, has not been 
shown to provide clinically important changes in 
behavior and academic performance of children with 
ADHD (Pelham et al., 1998). However, CBT might be 
helpful in treating symptoms of accompanying 
disorders such as oppositional defiant disorder, 
depression, or anxiety disorders (Abikoff, 1985; 
Hinshaw & Ehardt, 1991; Lochman, 1992). 



Psychoeducation 

Although there are no studies evaluating the efficacy of 
psychoeducation as a treatment modality for ADHD, 
providing information to parents, children, and teachers 
about ADHD and treatment options is considered 
critical in the development of a comprehensive 
treatment plan (AACAP, 1991). Educational 
accommodations for children with ADHD are federally 
mandated, and mental health providers are required to 
ensure that patients and families have access to 
adequate and appropriate educational resources. 
Organizations such as Children and Adults with 
Attention Deficit Disorder (CHADD) and the National 
Attention Deficit Disorder Association can be helpful 
sources of information and support for families. 

Multimodal Treatments 

Many researchers and families have long suspected that 
multimodal treatment — medication used together with J 
multiple psychosocial interventions in multiple 
settings — should be more effective than medication 
alone. Multimodal treatment has thus been used in the 
absence of empirical support (Hechtman, 1993). To 
determine whether multimodal treatment is indeed 
effective, the recent NIMH Multimodal Treatment M 
Study of ADHD (called the MTA Study) examined " 
three experimental conditions: medication management 
alone, behavioral treatment alone, or a combination of 
medication and behavioral treatments. The study 
compared the effectiveness of these three treatment 
modes with each other and with standard care provided 
in the community (the control group). The behavioral 
treatment condition consisted of parent training, a 
school intervention, and a summer treatment program. 
The MTA Study was also designed to determine the 
relative benefits of these treatments over time (Richters 
et al., 1995). All subjects were treated for 14 months 
and then followed for an additional 22 months. 

Results of the MTA Study comparing the 14-month 
outcomes of 579 children randomly assigned to one of 
the four treatment conditions were presented in the fall 
of 1998 (MTA Cooperative Group, 1998). At 14 d 
months, medication and the combination treatment 
were generally more effective than the behavioral 



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Children and Mental Health 



treatment alone or the control treatment. Notably, the 
combined treatment resulted in significant improve- 
ment over the control condition in six outcome 
areas — social skills, parent child relations, internalizing 
(e.g., anxiety) symptoms, reading achievement, 
oppositional and/or aggressive symptoms, and parent 
and/or consumer satisfaction — whereas the single 
forms of treatment (medication or behavior therapy) 
were each superiorto the control condition in only one 
to two of these domains. The conclusions from this 
major study are that carefully managed and monitored 
stimulant medication, alone or combined with 
behavioral treatment, is effective for ADHD over a 
period of 14 months. Addition of behavioral treatment 
yields no additional benefits for core ADHD symptoms 
but appears to provide some additional benefits for 
non-ADHD-symptom outcomes. 

Treatment Controversies 

Overprescription of Stimulants 
Concerns have been raised that children, particularly 
active boys, are being overdiagnosed with ADHD and 
thus are receiving psychostimulants unnecessarily. 
However, recent reports found little evidence of 
overdiagnosis of ADHD or overprescription of 
stimulant medications (Goldman et al., 1998; Jensen et 
al., 1999). Lideed, fewer children (2 to 3 percent of 
school-aged children) are being treated for ADHD than 
suffer from it. Treatment rates are much lower for 
selected groups such as girls, minorities, and children 
receiving care though public service systems (Bussing 
et al., 1998a, 1998b). However, there have been major 
increases in the number of stimulant prescriptions since 
1989 (Hoagwood et al., 1998), and methylphenidate is 
being manufactured at 2.5 times the rate of a decade 
ago (Goldman et al., 1998). Most researchers believe 
that much of the increased use of stimulants reflects 
better diagnosis and more effective treatment of a 
prevalent disorder. Medical and public awareness of 
the problem of ADHD has grown considerably, leading 
to longer treatment, fewer interruptions in treatment, 
and increased treatment of adults. Adolescents and 



younger girls with ADHD, who were underdiagnosed 
in the past, are being identified and treated. 

Nonetheless, some of the increase in use may 
reflect inappropriate diagnosis and treatment. In one 
study, the rate of stimulant treatment was twice the rate 
of parent-reported ADHD, based on a standardized 
psychiatric interview (Angold & Costello, 1998). While 
many children who do meet the full criteria for ADHD 
are not being treated, the majority of children and 
adolescents who are receiving stimulants did not fully 
meet the criteria. These findings may reflect a failure of 
proper, comprehensive evaluation and diagnosis rather 
than a failure of the diagnostic criteria, which are clear 
and validated by research (Angold & Costello, 1998). 
A diagnosis of ADHD requires the presence of 
impairing ADHD symptoms in multiple settings for at 
least 6 months. Although fidgeting and not paying 
attention are normal, common childhood behaviors, 
DSM-IV criteria reserve a diagnosis of ADHD for 
children in whom such frequent behavior produces 
persistent and pervasive dysfunction. An adequate 
diagnostic evaluation requires histories to be taken 
from multiple sources (parents, child, teachers), a 
medical evaluation of general and neurological health, 
a full cognitive assessment including school history, 
use of parent and teacher rating scales, and all 
necessary adjunct evaluation (such as assessment of 
speech, language). These evaluations take time and 
require multiple clinical skills. Regrettably, there is a 
dearth of appropriately trained professionals. 

Family practitioners are more likely than either 
pediatricians or psychiatrists to prescribe stimulants 
and less likely to use diagnostic services, provide 
mental health counseling, or provide followup care 
(Hoagwood et al., 1998). The American Academy of 
Pediatrics published a policy statement in 1996 on the 
use of medication for children with attentional 
disorders, concluding that use of medication should not 
be considered the complete treatment program for 
children with ADHD and should be prescribed only 
after a careful evaluation (American Academy of 
Pediatrics Committee on Children With Disabilities and 
Committee on Drugs, 1996). 



149 



Mental Health: A Report of the Surgeon General 



Safety of Long-Term Stimulant Use 
Even though the MTA Study found no safety issues 
over a 14-month period (Greenhill et al., 1998), 
concerns have been raised about the longer term safety 
of stimulant treatment. Since ADHD has an early onset 
and requires an extended course of treatment, research 
is needed to examine the long-term safety of treatment 
and to investigate whether other forms of treatment 
could be combined with psychostimulants to lower 
their dose as well as to reduce other problem behaviors 
found with ADHD. Such combined treatments could be 
targeted for symptoms of disorders that often 
accompany ADHD, such as conduct disorder, substance 
abuse, and learning disabilities, and could be targeted 
to improve overall functioning (Laufer, 1971; 
Gittelman et al., 1985). 

Because stimulants are also drugs of abuse and 
because children with ADHD are at increased risk for 
a substance abuse disorder, concerns have also been 
raised about the potential for abuse of stimulants by 
children taking the medication or diversion of the drug 
to others. While stimulants clearly have abuse 
potential, the rate of lifetime nonmedical methyl- 
phenidate use has not significantly increased since 
methylphenidate was introduced as a treatment for 
ADHD, suggesting that abuse is not a major problem 
(Goldman et al., 1998). Case reports describing abuse 
by children prescribed stimulants for ADHD are rare 
(Hechtman, 1985). 

Depression and Suicide in Children 
and Adolescents 

Li children and adolescents, the most frequently 
diagnosed mood disorders are major depressive 
disorder, dysthymic disorder, and bipolar disorder. 
Because mood disorders such as depression 
substantially increase the risk of suicide, suicidal 
behavior is a matter of serious concern for clinicians 
who deal with the mental health problems of children 
and adolescents. The incidence of suicide attempts 
reaches a peak during the midadolescent years, and 
mortality from suicide, which increases steadily 
through the teens, is the third leading cause of death at 
that age (CDC, 1999; Hoyert et al., 1999). Although 



suicide cannot be defined as a mental disorder, the 
various risk factors — especially the presence of mood 
disorders — that predispose young people to such 
behavior are given special emphasis in this section, as 
is a discussion of the effectiveness of various forms of 
treatment. The evidence is strong that over 90 percent 
of children and adolescents who commit suicide have 
a mental disorder, as explained later in this section. 

Major depressive disorder is a serious condition 
characterized by one or more major depressive 
episodes. Li children and adolescents, an episode lasts 
on average from 7 to 9 months (Birmaher et al., 1996a, 
1996b) and has many clinical features similar to those 
in adults. Depressed children are sad, they lose interest 
in activities that used to please them, and they criticize 
themselves and feel that others criticize them. They feel 
unloved, pessimistic, or even hopeless about the future; 
they think that life is not worth living, and thoughts of 
suicide may be present. Depressed children and 
adolescents are often irritable, and their irritability may 
lead to aggressive behavior. They are indecisive, have 
problems concentrating, and may lack energy or 
motivation; they may neglect their appearance and 
hygiene; and their normal sleep patterns are disturbed 
(DSM-IV). 

Despite some similarities, childhood depression 
differs in important ways from adult depression. 
Psychotic features do not occur as often in depressed 
children and adolescents, and when they occur, 
auditory hallucinations are more common than 
delusions (Ryan et al., 1987; Birmaher et al., 1996a, 
1996b). Associated anxiety symptoms, such as fears of 
separation or reluctance to meet people, and somatic 
symptoms, such as general aches and pains, 
stomachaches, and headaches, are more common in 
depressed children and adolescents than in adults with 
depression (Kolvin et al., 1991; Birmaher et al., 1996a, 
1996b). 

Dysthymic disorder is a mood disorder like major 
depressive disorder, but it has fewer symptoms and is 
more chronic. Because of its persistent nature, the 
disorder is especially likely to interfere with normal 
adjustment. The onset of dysthymic disorder (also 
called dysthymia) is usually in childhood or 



150 



Children and Mental Health 



adolescence (Akiskal, 1983; Klein et al., 1997). The 
child or adolescent is depressed for most of the day, on 
most days, and symptoms continue for several years. 
The average duration of a dysthymic period in children 
and adolescents is about 4 years (Kovacs et al., 1997a). 
Sometimes children are depressed for so long that they 
do not recognize their mood as out of the ordinary and 
thus may not complain of feeling depressed. Seventy 
percent of children and adolescents with dysthymia 
eventually experience an episode of major depression^ 
(Kovacs et al., 1994). When a combination of major 
depression and dysthymia occurs, the condition is 
referred to as double depression. 

Bipolar disorder is a mood disorder in which 
episodes of mania alternate with episodes of 
depression. Frequently, the condition begins in 
adolescence. The first manifestation of bipolar illness 
is usually a depressive episode. The first manic features 
may not occur for months or even years thereafter, or 
may occur either during the first depressive illness or 
later, after a symptom-free period (Strober et al., 1 995). 

The clinical problems of mania are very different 
from those of depression. Adolescents with mania or 
hypomania feel energetic, confident, and special; they 
usually have difficulty sleeping but do not tire; and 
they talk a great deal, often speaking very rapidly or 
loudly. They may complain that their thoughts are 
racing. They may do schoolwork quickly and creatively 
but in a disorganized, chaotic fashion. When manic, 
adolescents may have exaggerated or even delusional 
ideas about their capabilities and importance, may 
become overconfident, and may be "fresh" and 
uninhibited with others; they start numerous projects 
that they do not finish and may engage in reckless or 
risky behavior, such as fast driving or unsafe sex. 
Sexual preoccupations are increased and may be 
associated with promiscuous behavior. 

Reactive depression, also known as adjustment 
disorder with depressed mood, is the most common 
form of mood problem in children and adolescents. In 

^ Major depression refers to conditions marked by a major 
depressive episode, such as major depressive disorder, bipolar 
disorder, and related conditions. The word "major" refers to the 
number of symptoms. See Chapter 4 for DSM-IV diagnostic criteria. 



children suffering from reactive depression, depressed 
feelings are short-lived and usually occur in response to 
some adverse experience, such as a rejection, a sUght, 
a letdown, or a loss. In contrast, children may feel sad 
or lethargic and appear preoccupied for periods as short 
as a few hours or as long as 2 weeks. However, mood 
improves with a change in activity or an interesting or 
pleasant event. These transient mood swings in reaction 
to minor environmental adversities are not regarded as 
a form of mental disorder. 

Conditions Associated With Depression 

Roughly two-thirds of children and adolescents with 
major depressive disorder also have another mental 
disorder (Angold & Costello, 1993; Anderson & 
McGee, 1994). The most commonly associated 
disorders are dysthymia (see above), an anxiety 
disorder, a disruptive or antisocial disorder, or a 
substance abuse disorder. When more than one 
diagnosis is present, depression is more likely to begin 
after the onset of the accompanying disorder, except 
when that disorder is substance abuse (Biederman et 
al., 1995; Kessler & Walters, 1998). This suggests that, 
in some cases, depression may arise in response to the 
associated disorder. In other instances, such as the co- 
occurrence of conduct disorder and depression, the two 
may arise independently in response to inadequate 
maternal supervision and control, raising the possibility 
that parental behavior may be a risk factor for both 
conditions (Downey & Coyne, 1990; Rutter & 
Sandberg, 1992; Harrington, 1994). 

Prevalence 

Major Depression 

Population studies show that at any one time between 
10 and 15 percent of the child and adolescent 
population has some symptoms of depression (Smucker 
et al., 1986). The prevalence of the full-fledged 
diagnosis of major depression among all children ages 
9 to 17 has been estimated at 5 percent (Shaffer et al., 
1996c). Estimates of 1-year prevalence in children 
range from 0.4 and 2.5 percent and in adolescents, 
considerably higher (in some studies, as high as 8.3 



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Mental Health: A Report of the Surgeon General 



percent) (Anderson & McGee, 1994; Lewinsohn et al., 
1994a; Garrison etal., 1997; Kessler& Walters, 1998). 
For purposes of comparison, 1-year prevalence in 
adults is about 5.3 percent (Murphy et al., 1988; 
Rorsman et al., 1990; Regier et al., 1993). 

Dysthymic Disorder 

The prevalence of dysthymic disorder in adolescents 
has been estimated at around 3 percent (Garrison et al., 
1997). Before puberty, major depressive disorder and 
dysthymic disorder are equally common in boys and 
girls (Rutter, 1986). But after age 15, depression is 
twice as common in girls and women as in boys and 
men (Weissman & Klerman, 1977; McGee et al., 1990; 
Linehan etal., 1993). 

Suicide 

In 1996, the age-specific mortality rate from suicide 
was 1.6 per 100,000 for 10- to 14-year-olds, 9.5 per 
100,000 for 15- to 19-year-olds (i.e., about six times 
higher than in the younger age group; in this age group, 
boys are about four times as likely to commit suicide 
than are girls, while girls are twice as likely to attempt 
suicide), compared with 13.6 per 100,000 for 20- to 24- 
year-olds (CDC, 1999). Hispanic high school students 
are more likely than other students to attempt suicide 
(CDC, 1998). There have been some notable changes 
in these rates over the past few decades: since the early 
1960s, the reported suicide rate among 15- to 19-year- 
old males increased threefold but remained stable 
among females in that age group and among 10- to 14- 
year-olds (National Center for Health Statistics, 1998); 
the rate among white adolescent males reached a peak 
in the late 1980s (18.0 per 100,000 in 1986) and has 
since decUned somewhat (16.0 per 100,000 in 1997), 
whereas among African American male adolescents, 
the rate increased substantially in the same period 
(from 7.1 per 100,000 in 1986 to 11.4 per 100,000 in 
1997 (CDC, 1998). From 1979 to 1992, the Native 
American male adolescent and young adult suicide rate 
in Indian Health Service Areas was the highest in the 
Nation, with a suicide rate of 62.0 per 100,000 
(Wallace et al., 1996). 



It has been proposed that the rise in suicidal 
behavior among teenage boys results from increased 
availability of firearms (Boyd, 1983; Boyd &Moscicki, 
1986; Brent et al., 1987; Brent et al., 1991) and 
increased substance abuse in the youth population 
(Shaffer et al., 1996c; Birckmayer & Hemenway, 
1999). However, although the rate of suicide by 
firearms increased more than suicide by other methods 
(Boyd, 1983; Boyd & Moscicki, 1986; Brent et al., 
1987), suicide rates also increased markedly in many 
other countries in Europe, in Australia, and in New 
Zealand, where suicide by firearms is rare. 

Course and Natural History 

Most children with depression experience a recurrence. 
Twenty to 40 percent of depressed children relapse 
within 2 years, and 70 percent will do so by adulthood 
(Garber et al., 1988; Velez et al., 1989; Harrington et 
al., 1990; Fleming et al., 1993; Kovacs et al., 1994; 
Lewinsohn et al., 1994a; Garrison et al., 1997). The 
reasons for relapse are not known, but there is some 
evidence that experiencing a depression leaves behind 
psychological "scars" that may increase vulnerability 
throughout early life (see below). 

The age of first onset of depression appears to play 
a role in its course. Children who first become 
depressed before puberty are at risk for some form of 
mental disorder in adulthood, while teenagers who first 
become depressed after puberty are most likely to 
experience another episode of depression (Harrington 
et al., 1990; McCracken, 1992a; Lewinsohn et al., 
1994a, 1994b; Rao et al, 1995). These differences in 
outcome suggest that different mechanisms may lead to 
superficially similar but inherently different clinical 
conditions. Factors that worsen the prognosis for 
depressed children and adolescents include depression 
occurring in the context of conduct disorder (Harring- 
ton et al., 1990; Asarnow et al., 1994) and living in 
conflict-ridden families (Asarnow et al., 1994). 
Children and particularly adolescents who suffer from 
depression are at much greater risk of committing ^ 
suicide than are children without depression (Shaffer et 
al., 1996b). 



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Children and Mental Health 



The prognosis for dysthymia (Klein et al., 1997a) 
is unfavorable, with most patients continuing to feel 
depressed and to have social difficulties even after they 
have apparently recovered. The prognosis for double 
depressives (major depressive disorder plus dysthymia) 
is worse than that for either condition alone (Kovacs et 
al, 1994). 

Twenty to 40 percent of adolescents with depres- 
sion eventually develop bipolar disorder. Factors that 
predict later bipolar disorder include young age at the 
time of the first depressive episode, psychotic features 
in the initial depression, a family history of bipolar 
illness, and symptoms of hypomania developing during 
treatment with antidepressant drugs (Garber et al., 
1988; Strober et al., 1993). 

Causes 

The precise causes of depression are not known. 
Extensive research on adults with depression generally 
points to both biological and psychosocial factors 
(Kendler, 1995). However, there has been substantially 
less research on the causes of depression in children 
and adolescents. Further discussion of the risk factors 
for depression can be found in Chapter 4, as well as the 
preceding Overview of Risk Factors and Prevention 
section. 

Family and Genetic Factors 

Much of the research on children and adolescents with 
depression has been conducted with those who attend 
mental health clinics and with patients who tend to 
have the more severe and recurrent forms of 
depression, and thus they may not be representative of 
all children and adolescents with depression. With this 
Hmitation, research has shown that between 20 and 50 
percent of depressed children and adolescents have a 
family history of depression (Puig-Antich et al., 1989; 
Todd et al., 1993; Williamson et al., 1995; Kovacs, 
1997b). Family research has found that children of 
depressed parents are more than three times as likely as 
children with nondepressed parents to experience a 
depressive disorder (see Birmaher et al., 1996a, 1996b 
for a review). They also are more vulnerable to other 
mental and somatic disorders (Downey & Coyne, 



1990). Conversely, estimates of the proportion of 
depressed parents who have a depressed child or 
adolescent vary from approximately one in six to just 
under a half (Hammen et al., 1990). It is not clear 
whether the relationship between parent and childhood 
depression derives from genetic factors, or whether 
depressed parents create an environment that increases 
the likelihood of a mental disorder developing in their 
children (see below). 

Gender Differences 

One reason advanced to explain the greater prevalence 
of depression in adolescent girls (see above) is that they 
are more socially oriented, more dependent on positive 
social relationships, and more vulnerable to losses of 
social relationships than are boys (Allgood-Merten et 
al., 1 990). This would increase their vulnerability to the 
interpersonal stresses that are common in teenagers. 
There is also evidence that the methods girls use to 
cope with stress may entail less denial and more 
focused and repetitive thinking about the event (Nolen- 
Hoeksema & Girgus, 1994). The higher prevalence, 
therefore, could be a result of greater vulnerability, 
combined with coping mechanisms different than those 
of boys. 

Biological Factors 

Some of the core symptoms of depression, such as 
changes in appetite and sleep patterns, are related to the 
functions of the hypothalamus. The hypothalamus is, in 
turn, closely tied to the function of the pituitary gland. 
Abnormalities of pituitary function, such as increased 
rates of circulating Cortisol and hypo- or hyperthyroid- 
ism, are well established features of depression in 
adults (Goodwin & Jamison, 1990). However, far less 
research has been done in this area among children and 
adolescents (see Birmaher et al., 1996a, 1996b for a 
review). It is in the neuroendocrine area that most 
research has been done on child and adolescent 
depression (see Birmaher et al., 1996a, b). In suicidal 
adults dysregulation of the serotonergic system is 
common (Mann, 1998; Pine et al., 1995), making them 
typically impulsive, intense, and given to extreme 
reactions. However, little is known about the 



153 



Mental Health: A Report of the Surgeon General 

association between abnormal serotonin metabolism 
and suicidal behavior in children and adolescents. 

Cognitive Factors 

For over two decades there has been considerable 
interest in the relationship between a particular 
"mindset" or approach to perceiving external events 
and a predisposition to depression. The mindset in 
question is known as a pessimistic "attribution bias" 
(Abramson et al., 1978; Beck, 1987; Hops et al., 1990). 
A person with this mindset is one who readily assumes 
personal blame for negative events ("All the problems 
in the family are my fault"), who expects that one 
negative experience is part of a pattern of many other 
negative events ("Everything I do is wrong"), and who 
believes that a currently negative situation will endure 
permanently ("Nothing I do is going to make anything 
better"). Such pessimistic individuals take a 
characteristically negative view of positive events (i.e., 
that they are a result of someone else's effort, that they 
are isolated events, and that they are unlikely to recur). 
Individuals with this mindset react more passively, 
helplessly, and ineffectively to negative events than 
those without a pessimistic mindset (Seligman, 1975). 

There is uncertainty over whether this mindset 
precedes depression (and represents a permanent style 
of thinking as part of an individual's personality), is a 
manifestation of depression that is only present when 
the patient is depressed, and/or is a consequence or 
"scar" of a previous, perhaps unnoticed, depressive 
episode (Lewinsohn et al., 1981). This pessimistic 
mode of thinking does not occur in children under age 
5, which could be one of the reasons why depression 
and suicide are rare in early childhood (Rholes et al., 
1980; Rotenberg, 1982). 

There is evidence that children and adolescents 
who previously have been depressed may learn, during 
their depression, to interpret events in this fashion. This 
may make them prone to react similarly to negative 
events experienced after recovery, which could be one 
of the reasons why previously depressed children and 
adolescents are at continuing risk for depression 
(Nolen-Hoeksema et al., 1993). 



Perceptions of hopelessness, negative views about 
one's own competence, poor self- esteem, a sense of 
responsibility for negative events, and the immutability 
of these distorted attributions may contribute to the 
hopelessness that has been repeatedly found to be 
associated with suicidality (Overholser et al., 1995). 

Risk Factors for Suicide and Suicidal Behavior 

There is good evidence that over 90 percent of children 
and adolescents who commit suicide have a mental 
disorder before their death (Shaffer & Craft, 1 999). The 
most common disorders that predispose to suicide are 
some form of mood disorder, with or without 
alcoholism or other substance abuse problem, and/or 
certain forms of anxiety disorder (Shaffer et al., 
1996b). Psychological postmortem studies also show 
that a significant proportion of suicide victims suffered 
from an anxiety disorder at the time of their death, but 
the number of victims has been too small to yield 
precise odds ratios for the calculation of an effect. 
Although the rate of suicide is greatly increased in 
schizophrenia, because of its rarity, it accounts for very 
few suicides in the child and adolescent age group. 

Controlled studies of completed suicide suggest 
similar risk factors for boys and girls (Shafii et al., 
1985; Brent et al., 1988; GrohoU et al., 1997), but with 
marked differences in their relative importance (Shaffer 
et al., 1996c). 

Among girls, the most significant risk factor is the 
presence of major depression, which, in some studies, 
increases the risk of suicide 12-fold. The next most 
important risk factor is a previous suicide attempt, 
which increases the risk approximately threefold. 
Among boys, a previous suicide attempt is the most 
potent predictor, increasing the rate over 30-fold. It is 
followed by depression (increasing the rate by about 
12-fold), disruptive behavior (increasing the rate by 
twofold), and substance abuse (increasing the rate by 
just under twofold) (Shaffer et al., 1996c). 

Stressful life events often precede a suicide and/or 
suicide attempt (de Wilde et al., 1992; Gould et al., 
1996). As indicated earlier, these stressful life events 
include getting into trouble at school or with a law 



I 



154 



Children and Mental Health 



enforcement agency; a ruptured relationship with a 
boyfriend or a girlfriend; or a fight among friends 7 
They are rarely a sufficient cause of suicide, but they 
can be precipitating factors in young people. 

Controlled studies (Gould et al., 1996; Mollis, 
1996) indicate that low levels of communication 
between parents and children may act as a significant 
risk factor. While family discord, lack of family 
warmth, and disturbed parent-child relationship are 
commonly associated with child and adolescent 
psychopathology (violent behavior, mood disorder, 
alcohol and substance abuse disorders) (Brent et al., 
1994; Pfeffer et al., 1994), these factors do not play a 
specific role in suicide (Gould et al., 1998). 

Evidence has accumulated that supports the 
observation that suicide can be facilitated in vulnerable 
teens by exposure to real or fictional accounts of 
suicide (Velting & Gould, 1997), including media 
coverage of suicide, such as intensive reporting of the 
suicide of a celebrity, or the fictional representation of 
a suicide in a popular movie or TV show. The risk is 
especially high in the young, and it lasts for several 
weeks (Gould & Shaffer, 1986; Phillips et al., 1989). 
The suicide of a prominent person reported on 
television or in the newspaper or exposure to some 
sympathetic fictional representation of suicide may also 
tip the balance and make the at-risk individual feel that 
suicide is a reasonable, acceptable, and in some 
instances even heroic, decision (Gould & Shaffer, 
1986). 

The phenomenon of suicide clusters is presumed to 
be related to imitation (Davidson, 1989). Suicide 
clusters nearly always involve previously disturbed 
young people who knew about each other's death but 
rarely knew the other victims personally (Gould, 
personal communication, 1999). 



' The relationship between sexual orientation, depression, and 
suicidal thoughts and behavior is not well understood. Several 
studies suggest a link (Faullener & Cranston, 1998; Garofolo et al., 
1998;Garofoloetal., 1999). 



Consequences 

Both major depressive disorder and dysthymic disorder 
are inevitably associated with personal distress, and if 
they last a long time or occur repeatedly, they can lead 
to a circumscribed life with fewer friends and sources 
of support, more stress, and missed educational and job 
opportunities (Klein et al., 1997). The psychological 
scars of depression include an enduring pessimistic 
style of interpreting events, which may increase the risk 
of further depressive episodes. Impairment is greater 
for those with dysthymic disorder than for those with 
major depression (Klein et al., 1997a), presumably 
because of the longer duration of depression in 
dysthymic disorder, which is also a prime risk factor 
for suicide. In a 10- to 15 -year followup study of 73 
adolescents diagnosed with major depression, 7 percent 
of the adolescents had committed suicide sometime 
later. The depressed adolescents were five times more 
likely to have attempted suicide as well, compared with 
a control group of age peers without depression 
(Weissman et al., 1999). 

Treatment 

Depression 

Psychosocial Interventions 

To be deemed effective and approved by the American 
Psychological Association, treatments for mental 
disorders have to meet very strict criteria. While 
interpersonal therapy and systemic family therapy show 
promise, they have not been studied sufficiently to 
evaluate their effectiveness by these standards. 
However, in a comprehensive review article (Kaslow & 
Thompson, 1998) that evaluated interventions for 
depression in children and adolescents against the 
American Psychological Association Task Force 
criteria, two forms of cognitive-behavioral therapy 
(CBT) were found to be "probably effective 
treatments," although none of the interventions for 
depression were deemed, as yet, to meet the 
Association's higher standard for a well-established 
intervention. 



155 



Mental Health: A Report of the Surgeon General 



In studies that focused on relieving symptoms of 
depression in preadolescents, only one form of CBT 
met the criteria for a probably effective intervention. In 
the first study, the relative efficacy of two types of 
CBT — 12-session group interventions based on either 
self-control therapy or behavior-solving therapy — were 
compared with a "waiting list" control group (Stark et 
al., 1987). Children responded to both CBT inter- 
ventions with fewer symptoms of depression and 
anxiety, whereas the waiting list group exhibited 
minimal change. Because improvement was greatest 
with self-control therapy, this intervention was 
compared in a later study with a traditional counseling 
condition. Self-control therapy, enhanced by doubling 
the number of sessions, entailed social skills training, 
assertiveness training, relaxation training and imagery, 
and cognitive restructuring. Monthly family meetings 
were also added to both the experimental and control 
conditions. Children receiving self-control therapy 
reported fewer symptoms at 7-month followup (Stark 
etal., 1991). 

Among the numerous studies of adolescents 
reviewed by Kaslow and Thomson (1998), one form of 
CBT — coping skills — was judged probably effi- 
cacious. This intervention, based on the "Coping with 
Depression" course, was developed originally in 
Oregon for adults by Lewinsohn and colleagues 
(Lewinsohn et al., 1996) and adapted by Clarke and 
colleagues (1992) for school-based programs to treat 
adolescent depression. Compared with controls on the 
waiting list, adolescents who received CBT had lower 
rates of depression, less self-reported depression, 
improvement in cognitions, and increased activity 
levels (Lewinsohn et al., 1990, 1996). To achieve well- 
established status, as defined by the American Psycho- 
logical Association Task Force, the intervention has to 
be studied by another team of investigators — which has 
not as yet been done. 



Pharmacological Treatment 

Prior to 1996, the medications of choice for major 
depression in children and adolescents were the 
tricyclic antidepressants, a choice based on numerous 
studies in adults. However, 13 distinct trials in children 
and adolescents failed to demonstrate the efficacy of 
tricyclic antidepressants for younger ages. Tricyclic 
antidepressants also have a higher risk of toxicity than 
selective serotonin reuptake inhibitors (SSRIs) (Walsh 
et al., 1994; Kutcher, 1998). The current consensus is 
that tricyclic medications are not the medication of 
choice for depressed children and adolescents 
(Eisenberg, 1996; Fisher & Fisher, 1996). 

Recent research indicates that young people with 
depressive disorders may respond more favorably to 
SSRIs than to tricyclic antidepressants. The first SSRI 
tested in children and adolescents was fluoxetine. In a 
study of 96 outpatients over 8 weeks, 56 percent 
receiving fluoxetine and 33 percent receiving placebo 
were "much" or "very much" improved on the Clinical 
Global Improvement Scale. Benefits were comparable 
across age groups. Complete symptom remission 
occurred for 3 1 percent of fluoxetine-treated patients 
compared with 23 percent of placebo-treated patients 
(Emslie et al., 1997). A recent open trial of fluoxetine 
for adolescents hospitalized for treatment of major 
depression found it to decrease depression scores more 
effectively than imipramine, a tricyclic antidepressant 
(Strober et al., 1999), with the further advantage that 
fluoxetine was well tolerated. 

The safety of a second SSRI, paroxetine, was 
demonstrated in a multicenter double-blind placebo- 
controlled trial. Paroxetine was compared with 
imipramine and placebo in 275 adolescents who met 
the DSM-IV criteria for major depression. Preliminary 
results indicate that, mostly because of side effects, 
one-third of imipramine patients withdrew from the 
study, a proportion significantly higher than that for 
paroxetine (10 percent) and placebo (7 percent) 
(Wagner et al., 1998). One of the co-investigators of 
this study noted that paroxetine's efficacy was superior 



156 



Children and Mental Health 



to that of imipramine and placebo on the Clinical 
Global Improvement Scale (Graham EmsUe, personal 
communication, October 1998). However, final 
conclusions about the benefit of this second SSRI must 
await publication of the outcomes of this multicenter 
study. 

In summary, psychosocial interventions for 
depressed children and adolescents indicate great 
promise, with several types of cognitive-behavioral 
therapy for the child or adolescent leading the way. 
With respect to pharmacotherapy, new studies attest to 
the safety and efficacy of two SSRIs. These promising 
findings are being extended in the recently begun 
NIMH-funded Treatment of Adolescents with 
Depression study. 

Bipolar Disorder 

Pharmacological Treatment 

The treatment of bipolar disorder entails treating 
symptoms of both depression and mania. For decades, 
lithium has been the well-researched mainstay 
treatment for mania in adults. Mania in bipolar disorder 
of children is also treated with lithium, although the 
relevant research on children lags behind that on adults. 
Only in recent years have researchers begun to study 
lithium in children and adolescents, with good clinical 
response. Open trials of lithium were conducted in the 
late 1980s (Varanka et al., 1988; Strober et al., 1990). 
More recently, lithium proved to be more effective than 
placebo in treating adolescents who were bipolar and 
substance dependent (Geller et al., 1998). 

Children experience the same safety problems with 
lithium as do adults: toxicity and impairment of renal 
and thyroid functioning (Geller & Luby, 1997). 
Lithium is therefore not recommended for families 
unable to keep regular appointments that would ensure 
monitoring of serum lithium levels and of adverse 
events. Patients who discontinue taking the drug have 
a high relapse rate (Strober et al., 1990). 

As yet, there are no controlled studies on a number 
of other psychotropic agents also used clinically in 
children and adolescents with bipolar disorder, 



including valproate, carbamazepine, methylphenidate, 
and low-dose chlorpromazine (Campbell & Cueva, 
1995; Geller & Luby, 1997). 

Suicide 

Psychotherapeutic Treatments 
Suicidal children and adolescents report feelings of 
intense emotional distress involving depression, anger, 
anxiety, hopelessness, and worthlessness and an 
inability to change problematic, frustrating 
circumstances or to find a solution to their problems 
(Kienhorst et al., 1995; Ohring et al., 1996). They feel 
so distraught that they often respond impulsively to 
their despair. Psychotherapeutic techniques aim to 
decrease such intolerable feelings and thoughts and to 
re-orient the cognitive and emotional perspectives of 
the suicidal child or adolescent (Kemberg, 1994; 
Spirito, 1997). 

Cognitive-behavioral therapy (CBT) may be a 
useful intervention, considering that suicidal children 
and adolescents often experience negative cognitions 
about themselves, their environment, and their futures. 
Recent research suggests that CBT may be more 
effective than systemic behavior family therapy or 
individual nondirective supportive therapy in reducing 
depressive symptoms associated with suicidal ideation 
(Brent et al., 1997). Such treatment can focus on re- 
attribution of precipitating issues for suicidal behavior 
and enable the suicidal child or adolescent to rank 
stresses and to consider avenues of problem-solving 
(Rotheram-Borus et al., 1994; Brent et al, 1997; 
Spirito, 1997). 

Interpersonal conflicts are important stresses 
related to the risk imparted by poor social adjustment 
of potentially suicidal children and adolescents. 
Treatment of interpersonal strife may significantly 
reduce suicidal risk. Recent research into the efficacy 
of interpersonal psychotherapy of depressed 
adolescents suggests beneficial effects (Kaslow & 
Thompson, 1998); it is a treatment that may be 
modified to address the risk factor issues related to 
interpersonal loss, conflicts, and need for restitution 



157 



Mental Health: A Report of the Surgeon General 



often reported by children and adolescents with suicidal 
tendencies. 

A significant class of risk factors for suicide 
involves family discord, which is characterized by poor 
communication, disagreements, and lack of cohesive 
values and goals and of common activities (de Long, 
1992; Miller et al., 1992; Wagner, 1997). Suicidal 
children and adolescents often feel that they are 
isolated within the family, exhibit problems in 
independence, and view themselves as expendable to 
the family, a perception that is a motivating force for 
self-annihilation (Sabbath, 1969; Pfeffer, 1986; Miller 
et al., 1992). Family intervention with suicidal children 
and adolescents is an important method to decrease 
such problems and to enhance effective family 
problem-solving and conflict resolution, so that blame 
is not directed toward the suicidal child or adolescent. 
Cognitive-behavioral approaches with suicidal children 
and adolescents and their families aim to reframe their 
understanding of family problems, alter the family style 
of maladaptive problem-solving techniques, and 
encourage positive family interactions (Rotheram- 
Borus et al., 1994). Time-limited home-based 
intervention to reduce suicidal ideation in children and 
adolescents and to improve family functioning has been 
reported to have limited efficacy for children and 
adolescents without major depressive disorder 
(Harrington et al., 1998). Psychoeducational approach- 
es to reduce the extent of expressed anger may be 
helpful in lowering risk for suicidal behavior in 
children and adolescents (Fristad et al., 1996). 

Psychopharmacological Treatments 
There is a dearth of research on the efficacy of 
pharmacological treatments for reducing suicidal 
thoughts or preventing suicide in children and 
adolescents. Most of the research on pharmacotherapies 
has been conducted in adults, hi depressed adults, 
SSRIs have been found to reduce suicidal ideation 
(Letizia et al., 1996; Wernicke et al., 1997) and to 
reduce the frequency of suicide attempts in 
nondepressed patients who had previously made at least 
one suicide attempt (Verkes et al., 1998). hi a 



controlled trial of the experimental neuroleptic drug 
flupenthixol, researchers noted a significant reduction 
in suicide-attempt behavior in adults who had made 
numerous previous attempts (Montgomery & 
Montgomery, 1982). Similar studies have yet to be 
conducted on adolescents, although trials of SSRIs in 
depressed adolescents suggest that these drugs are 
effective for treating depression and for reducing 
suicidal ideas also in this age group (Emslie et al., 
1997; Ryan & Varma, 1998). Because placebo- 
controlled, methodologically appropriate studies of 
tricyclic antidepressants have failed to find a significant 
effect in depressed children and adolescents (Ryan & 
Varma, 1998), it is reasonable to regard SSRIs as a 
first-choice medication in treating depressed suicidal 
children and adolescents (also see American Academy 
of Child and Adolescent Psychiatry, 1998). In contrast 
to tricyclic antidepressants, SSRIs have low lethal 
potential when taken in overdoses (Ryan & Varma, 
1998). 

In adults with major depressive disorder, controlled 
research suggests that lithium reduces suicide risk 
(Thies-Flechtner et al., 1996), but this has not yet been 
demonstrated in children and adolescents. Clinicians 
should be cautious about prescribing medications that 
may reduce self-control, such as the benzodiazapines, 
amphetamines, and phenobarbital. These drugs also 
have a high lethal potential if taken in overdose 
(Carlsten et al., 1996). 

Intervention After a Suicidal Death of a Relative, 
Friend, or Acquaintance 

The suicidal death of a relative or acquaintance may 
increase the risk for childhood or adolescent suicidal 
behavior and other dysphoric states (Brent et al., 1992, 
1994; Pfeffer et al, 1994, 1997; Clark & Goebel, 
1996). Major depression, post-traumatic stress disorder, 
and suicidal ideation often occur after the death of an 
adolescent friend or acquaintance and relative (Brent et 
al., 1992, 1994, 1996). 

The goal of the clinician is to decrease the 
hkelihood that a child or adolescent comes to view the 
suicidal behavior of the deceased as a coping strategy 
in deaUng with adversity (Brent et al., 1997). Psycho- 



158 



Children and Mental Health 



educational counseling may reduce the risk for suicidal 
behavior in these circumstances. Intervention is also 
needed to decrease the child's or teen's personal sense 
of guilt, trauma, and social isolation. This treatment can 
be given in individual meetings, at group sessions with 
other teens, or in conjunction with parents who need 
help to support the adaptive capacities of their children 
and adolescents. School professionals sometimes offer 
programs of this kind and can be invaluable in 
identifying grieving friends who may need help. 

Community-Based Suicide Prevention 
The principal public health approaches to suicide 
prevention have been (1) crisis hotlines^; (2) restric- 
tions covering access to suicide methods; (3) media 
counseling to minimize imitative suicide; (4) indirect 
case-finding by educating potential gate-keepers, 
teachers, parents, and peers to identify the warning 
signs of an impending suicide; (5) direct case-fmding 
among high school or college students or among the 
patients of primary practitioners by screening for 
conditions that place teens at risk for suicide; and (6) 
training professionals to improve recognition and 
treatment of mood disorders. As discussed below, the 
level of evidence for these strategies varies. There is 
more support for direct case-finding and improved 
recognition and treatment of mood disorders than for 
the other strategies. 



before a call is answered, so that callers disconnect; the 
advice individuals get on calling a hotline may be 
stereotyped, inappropriate for an individual's needs, 
and perceived as unhelpful by the caller. Gender 
preferences in seeking help result in the large majority 
of callers being females, whereas males are at greatest 
risk for suicide. While each of these deficiencies is 
potentially modifiable, there have been no systematic 
attempts to do so. 

Method Restriction 

Method preference for suicide varies by gender and by 
nationality. In the United States, the most common 
method for committing suicide is by firearms, and it has 
been suggested that reducing firearms availability will 
reduce the incidence of suicide (Moscicki, 1995). 
However, a natural experiment in Great Britain 
suggests this is unlikely. The favored suicide method, 
self-asphyxiation with coal gas, became impossible 
after the introduction of natural gas. This resulted in a 
marked but short-lived decline in the suicide rate. 
Within a decade, the suicide rate had returned to 
previous levels, and suicides were being committed by 
other means (Farberow, 1985). Although reducing 
access to firearms with gun-security laws reduces 
accidental deaths from firearms (Cummings et al., 
1997), there is no evidence to date that such laws have 
a significant impact on suicides attributable to firearms. 



Crisis Hotlines 

Although crisis hotlines are available almost every- 
where in the United States, research has failed to show 
that they reduce the incidence of suicide (Bleach & 
Clairbom, 1974; Apsler & Hodas, 1976; Miller et al., 
1984; Shaffer et al, 1990a, 1990b). Possible reasons 
for this are that actively suicidal individuals (males and 
individuals with an acute mental disturbance) do not 
call hotlines because they are acutely disturbed, 
preoccupied, or intent on not being deflected from their 
intended course of action (Shaffer et al., 1989). 
Hodines are often busy, and there may be a long wait 



* Crisis hotlines are only one of the services offered through crisis 
services, a topic discussed subsequently. 



Media Counseling 

Even though it appears prudent for reporters and editors 
to minimize coverage of youth suicide in general and 
attention to individual suicides (O' Carroll & Potter, 
1994), there is as yet no evidence that these guidelines, 
issued by the Centers for Disease Control and 
Prevention, are effective in reducing the suicide rate. 

Indirect Case-Finding Through Education 
Controlled studies have failed to show that classes for 
high school students about suicide increase students' 
help-seeking behavior when they are troubled or 
depressed (Spirito et al., 1988; Shaffer et al., 1991; 
Vieland et al., 1991). On the other hand, there is 
evidence that previously suicidal adolescents are upset 



159 



Mental Health: A Report of the Surgeon General 



by exposure to such classes (Shaffer et al., 1990a, 
1990b), even though this does not necessarily lead to a 
suicide attempt. Such educational programs seem, 
therefore, to be both an ineffective mode of case- 
finding and to carry with them an unjustified risk of 
activating suicidal thoughts. 

Direct Case-Finding 

Judging from the high response rate to surveys about 
suicidal attempts and ideation (National Center for 
Health Statistics, 1997), adolescents will provide 
accurate information about their own suicidal thoughts 
and/or behaviors if asked directly in a nonthreatening 
way. A sensible approach to suicide prevention that 
needs further study, therefore, is to screen 
systematically 15- to 19-year-olds (the age group at 
greatest risk) for (1) previous suicide attempts; 
(2) recent, serious, suicidal preoccupations; (3) depres- 
sion; or (4) complications of substance or alcohol use. 
Clearly, screening programs need to go beyond 
identifying a teen with a high-risk profile. Youth 
identified in this way should be referred for evaluation 
and, if necessary, treatment. Contingency arrangements 
may need to be made to assist uninsured adolescents 
with help if it is needed (Shaffer & Craft, 1999). 

Aggressive Treatment of Mood Disorders 
Preliminary and as yet unreplicated studies in Sweden 
(Rihmer et al., 1995) suggest that education of primary 
medical practitioners to better identify the 
characteristics of mood disorders and to treat these 
effectively produced a significant reduction in suicide 
and suicide-attempt rates. Although the optimal 
treatment of adolescent depression is not yet as well 
understood as that of adult depression, this is an option 
that may prove to be useful. 

Air Force Suicide Prevention Program — A 
Community Approach 

Combining many of the approaches for adolescents 
described above, the Air Force Surgeon General 
developed and implemented a community approach to 
suicide prevention for older adolescents and young 
adults on active duty. The program involved education 



on suicide risk awareness, reducing barriers to mental 
health services, and stigma-reducing efforts.^ 

Other Mental Disorders in Children 
and Adolescents 

Anxiety Disorders 

The combined prevalence of the group of disorders 
known as anxiety disorders is higher than that of 
virtually all other mental disorders of childhood and 
adolescence (Costello et al., 1996). The 1-year 
prevalence in children ages 9 to 17 is 13 percent (Table 
3-1). This section furnishes brief overviews of several 
anxiety disorders: separation anxiety disorder, 
generalized anxiety disorder, social phobia, and 
obsessive-compulsive disorder. Treatments for all but 
the latter are grouped together below. 

Separation Anxiety Disorder 

Although separation anxieties are normal among 
infants and toddlers, they are not appropriate for older 
children or adolescents and may represent symptoms of 
separation anxiety disorder. To reach the diagnostic 
threshold for this disorder, the anxiety or fear must 
cause distress or affect social, academic, or job 
functioning and must last at least 1 month (DSM-FV). 
Children with separation anxiety may cling to their 
parent and have difficulty falling asleep by themselves 
at night. When separated, they may fear that their 
parent will be involved in an accident or taken ill, or in 
some other way be "lost" to the child forever. Their 
need to stay close to their parent or home may make it 
difficult for them to attend school or camp, stay at 
friends' houses, or be in a room by themselves. Fear of 
separation can lead to dizziness, nausea, or palpitations 
(DSM-IV). 

Separation anxiety is often associated with 
symptoms of depression, such as sadness, withdrawal, 
apathy, or difficulty in concentrating, and such children 
often fear that they or a family member might die. 

' In 1995, prior to implementation, suicide rates were almost 16 per 
100,000; following 3 years of exposure to the program, suicide rates 
fell to below 2 per 100,000 (Air Force Surgeon General, personal 
communication, 1999) 



160 



Children and Mental Health 



Young children experience nightmares or fears at 
bedtime. 

About 4 percent of children and young adolescents 
suffer from separation anxiety disorder (DSM-FV). 
Among those who seek treatment, separation anxiety 
disorder is equally distributed between boys and girls. 
In survey samples, the disorder is more common in 
girls (DSM-IV). The disorder may be overdiagnosed in 
children and teenagers who live in dangerous 
neighborhoods and have reasonable fears of leaving 
home. 

The remission rate with separation anxiety disorder 
is high. However, there are periods where the illness is 
more severe and other times when it remits. Sometimes 
the condition lasts many years or is a precursor to panic 
disorder with agoraphobia. Older individuals with 
separation anxiety disorder may have difficulty moving 
or getting married and may, in turn, worry about 
separation from their own children and partner. 

The cause of separation anxiety disorder is not 
known, although some risk factors have been identified. 
Affected children tend to come from families that are 
very close-knit. The disorder might develop after a 
stress such as death or illness in the family or a move. 
Trauma, especially physical or sexual assault, might 
bring on the disorder (Goenjian et al., 1995). The 
disorder sometimes runs in families, but the precise 
role of genetic and environmental factors has not been 
established. The etiology of anxiety disorders is more 
thoroughly discussed in Chapter 4. 

Generalized Anxiety Disorder 

Children with generalized anxiety disorder (or 
overanxious disorder of childhood) worry excessively 
about all manner of upcoming events and occurrences. 
They worry unduly about their academic performance 
or sporting activities, about being on time, or even 
about natural disasters such as earthquakes. The worry 
persists even when the child is not being judged and 
has always performed well in the past. Because of their 
anxiety, children may be overly conforming, 
perfectionist, or unsure of themselves. They tend to 
redo tasks if there are any imperfections. They tend to 
seek approval and need constant reassurance about 



their performance and their anxieties (DSM-IV). The 1- 
year prevalence rate for all generalized anxiety disorder 
sufferers of all ages is approximately 3 percent. The 
lifetime prevalence rate is about 5 percent (DSM-IV). 
About half of all adults seeking treatment for this 
disorder report that it began in childhood or 
adolescence, but the proportion of children with this 
disorder who retain the problem into adulthood is 
unknown. The remission rate is not thought to be as 
high as that of separation anxiety disorder. 

Social Phobia 

Children with social phobia (also called social anxiety 
disorder) have a persistent fear of being embarrassed in 
social situations, during a performance, or if they have 
to speak in class or in public, get into conversation with 
others, or eat, drink, or write in public. Feelings of 
anxiety in these situations produce physical reactions: 
palpitations, tremors, sweating, diarrhea, blushing, 
muscle tension, etc. Sometimes a full-blown panic 
attack ensues; sometimes the reaction is much more 
mild. Adolescents and adults are able to recognize that 
their fear is unreasonable or excessive, although this 
recognition does not prevent the fear. Children, 
however, might not recognize that their reaction is 
excessive, although they may be afraid that others will 
notice their anxiety and consider them odd or babyish. 

Young children do not articulate their fears, but 
may cry, have tantrums, freeze, cling, appear extremely 
timid in strange social settings, shrink from contact 
with others, stay on the side during social events, and 
try to stay close to familiar adults. They may fall 
behind in school, avoid school completely, or avoid 
social activities among children their age. The 
avoidance of the fearful situations or worry preceding 
the feared event may last for weeks and interfere with 
the individual's daily routine, social life, job, or school. 
They may find it impossible to speak in social 
situations or in the presence of unfamiliar people (for 
review of social phobia, see DSM-IV; Black et al., 
1997). 

Social phobia is common, the lifetime prevalence 
ranging from 3 to 1 3 percent, depending on how great 
the fear is and on how many different situations induce 



161 



Mental Health: A Report of the Surgeon General 

the anxiety (DSM-IV; Black et al., 1997). In survey 
studies, the majority of those with the disorder were 
found to be female (DSM-IV). Often the illness is 
lifelong, although it may become less severe or 
completely remit. Life events may reassure the 
individual or exacerbate the anxiety and disorder. 

Treatment of Anxiety 

Although anxiety disorders are the most common 
disorder of youth, there is relatively little research on 
the efficacy of psychotherapy (Kendall et al., 1997). 
For childhood phobias, contingency management'" was 
the only intervention deemed to be well-established, 
according to an evaluation by Ollendick and King 
(1998), which applied the American Psychological 
Association Task Force criteria (noted earlier). Several 
psychotherapies are probably efficacious for treating 
phobias: systematic desensitization"; modeUng, based 
on research by Bandura and colleagues, which 
capitalizes on an observational learning technique 
(Bandura, 197 1 ; see also Chapter 2); and several cogni- 
tive-behavioral therapy (CBT) approaches (Ollendick 
& King, 1998). 

CBT, as pioneered by Kendall and colleagues 
(Kendall et al., 1992; Kendall, 1994), is deemed by the 
American Psychological Association Task Force as 
probably efficacious. It has four major components: 
recognizing anxious feelings, clarifying cognitions in 
anxiety-provoking situations,'' developing a plan for 
coping, and evaluating the success of coping strategies. 
A more recent study in Australia added a parent 
component to CBT, which enhanced reduction in post- 
treatment anxiety disorder significantly compared with 
CBT alone (Barrett et al, 1996). However, none of the 
interventions identified above as well-established or 
probably efficacious has, for the most part, been tested 
in real- world settings. 



'" Contingency management attempts to alter behavior by 
manipulating its consequences through the behavioral principles of 
shaping, positive reinforcement, and extinction. 

" A technique that trains people to "unlearn" fears by presentation 
of fearful stimuli along with nonfearful stimuli. 

'^ This refers to understanding how cognitions are being distorted. 



In addition, psychodynamic treatment to address 
underlying fears and worries can be helpful, and 
behavior therapy may reduce the child's fear of 
separation or of going to school; however, the 
experimental support for these approaches is limited. 

Preliminary research suggests that selective 
serotonin reuptake inhibitors may provide effective 
treatment of separation anxiety disorder and other 
anxiety disorders of childhood and adolescence. Two 
large-scale randomized controlled trials are currently 
being undertaken (Greenhill, 1998a, 1998b). Neither 
tricyclic antidepressants nor benzodiazepines have been 
shown to be more effective than placebo in children 
(Klein et al., 1992; Bernstein et al., 1998). 

Obsessive-Compulsive Disorder 

Obsessive-compulsive disorder (OCD), which is 
classified in DSM-IV as an anxiety disorder, is 
characterized by recurrent, time-consuming obsessive 
or compulsive behaviors that cause distress and/or 
impairment. The obsessions may be repetitive intrusive 
images, thoughts, or impulses. Often the compulsive 
behaviors, such as hand-washing or cleaning rituals, are 
an attempt to displace the obsessive thoughts 
(DSM-IV). Estimates of prevalence range from 0.2 to 
0.8 percent in children, and up to 2% of adolescents 
(Flament et al., 1998). 

There is a strong familial component to OCD, and 
there is evidence from twin studies of both genetic 
susceptibility and environmental influences. If one twin 
has OCD, the other twin is more likely to have OCD if 
the children are identical twins rather than fraternal 
twin pairs. OCD is increased among first-degree 
relatives of children with OCD, particularly among 
fathers (Lenane et al., 1990). It does not appear that the 
child is simply imitating the relative's behavior, 
because children who develop OCD tend to have 
symptoms different from those of relatives with the 
disease (Leonard et al., 1997). Many adults with either 
childhood- or adolescent-onset of OCD show evidence 
of abnormalities in a neural network known as the 
orbitofrontal-striatal area (Ranch & Savage, 1997; 
Grachev et al., 1998). 



162 



Recent research suggests that some children with 
OCD develop the condition after experiencing one type 
of streptococcal infection (Swedo et al., 1995). This 
condition is referred to by the acronym PANDAS, 
which stands for Pediatric Autoimmune Neuro- 
psychiatric Disorders Associated with Streptococcal 
infections. Its hallmark is a sudden and abrupt 
exacerbation of OCD symptoms after a strep infection. 
This form of OCD occurs when the immune system 
generates antibodies to the streptococcal bacteria, and 
the antibodies cross-react with the basal ganglia'^ of a 
susceptible child, provoking OCD (Garvey et al., 
1998). In other words, the cause of this form of OCD 
appears to be antibodies directed against the infection 
mistakenly attacking a region of the brain and setting 
off an inflammatory reaction. 

The selective serotonin reuptake inhibitors appear 
effective in ameliorating the symptoms of OCD in 
children, although more clinical trials have been done 
with adults than with children. Several randomized, 
controlled trials revealed SSRIs to be effective in 
treating children and adolescents with OCD (Flament 
et al., 1985; DeVeaugh-Geiss et al., 1992; Riddle et al., 
1992, 1998). The appropriate duration of treatment is 
still being studied. Side effects are not inconsequential: 
dry mouth, somnolence, dizziness, fatigue, tremors, and 
constipation occur at fairly high rates. Cognitive- 
behavioral treatments also have been used to treat OCD 
(March et al., 1997), but the evidence is not yet 
conclusive. 

Autism 

Autism, the most common of the pervasive develop- 
mental disorders (with a prevalence of 10 to 12 
children per 10,000 [Bryson & Smith, 1998]), is 
characterized by severely compromised ability to 
engage in, and by a lack of interest in, social 
interactions. It has roots in both structural brain 
abnormalities and genetic predispositions, according to 
family studies and studies of brain anatomy. The search 
for genes that predispose to autism is considered an 



'^ Basal ganglia are groups of neurons responsible for motor and 
impulse control, attention, and regulation of mood and behavior. 



Children and Mental Health 

extremely high research priority for the National 
Institute of Mental Health (NIMH, 1998). Although the 
reported association between autism and obstetrical 
hazard may be due to genetic factors (Bailey et al., 
1995), there is evidence that several different causes of 
toxic or infectious damage to the central nervous 
system during early development also may contribute 
to autism. Autism has been reported in children with 
fetal alcohol syndrome (Aronson et al., 1997), in 
children who were infected with rubella during 
pregnancy (Chess et al., 1978), and in children whose 
mothers took a variety of medications that are known to 
damage the fetus (Williams & Hersh, 1997). 

Cognitive deficits in social perception likely result 
from abnormalities in neural circuitry. Children with 
autism have been studied with several imaging 
techniques, but no strongly consistent findings have 
emerged, although abnormalities in the cerebellum and 
limbic system (Rapin & Katzman, 1998) and larger 
brains (Piven, 1997) have been reported. In one small 
study (Zilbovicius et al., 1995), evidence of delayed 
maturation of the frontal cortex was found. The 
evidence for genetic influences include a much greater 
concordance in identical than in fraternal twins (Cook, 
1998). 

Treatment 

Because autism is a severe, chronic developmental 
disorder, which results in significant lifelong disability, 
the goal of treatment is to promote the child's social 
and language development and minimize behaviors that 
interfere with the child's functioning and learning. 
Intensive, sustained special education programs and 
behavior therapy early in life can increase the ability of 
the child with autism to acquire language and ability to 
learn. Special education programs in highly structured 
environments appear to help the child acquire self -care, 
social, and job skills. Only in the past decade have 
studies shown positive outcomes for very young 
children with autism. Given the severity of the 
impairment, high intensity of service needs, and costs 
(both human and financial), there has been an ongoing 
search for effective treatment. 



163 



Mental Health: A Report of the Surgeon General 



Thirty years of research demonstrated the efficacy 
of applied behavioral methods in reducing inap- 
propriate behavior and in increasing communication, 
learning, and appropriate social behavior. A well- 
designed study of a psychosocial intervention was 
carried out by Lovaas and colleagues (Lovaas, 1987; 
McEachin et al., 1993). Nineteen children with autism 
were treated intensively with behavior therapy for 2 
years and compared with two control groups. Followup 
of the experimental group in first grade, in late 
childhood, and in adolescence found that nearly half 
the experimental group but almost none of the children 
in the matched control group were able to participate in 
regular schooling. Up to this point, a number of other 
research groups have provided at least a partial 
replication of the Lovaas model (see Rogers, 1998). 

Several uncontrolled studies of comprehensive 
center-based programs have been conducted, focusing 
on language development and other developmental 
skills. A comprehensive model. Treatment and 
Education of Autistic and Related Communication 
Handicapped Children (TEACCH), demonstrated short- 
term gains for preschoolers with autism who received 
daily TEACCH home-teaching sessions, compared with 
a matched control group (Ozonoff & Cathcart, 1998). 
A review of other comprehensive, center-based 
programs has been conducted, focusing on elements 
considered critical to school-based programs, including 
minimum hours of service and necessary curricular 
components (Dawson & Osterling, 1997). 

The antipsychotic drug, haloperidol, has been 
shown to be superior to placebo in the treatment of 
autism (Perry et al., 1989; Locascio et al., 1991), 
although a significant number of children develop 
dyskinesias''* as a side effect (Campbell et al., 1997). 
Two of the SSRIs, clomipramine (Gordon et al., 1993) 
and fluoxetine (McDougle et al., 1996), have been 
tested, with positive results, except in young autistic 
children, in whom clomipramine was not found to be 
therapeutic, and who experienced untoward side effects 
(Sanchez et al., 1996). Of note, preUminary studies of 



''' Dyskinesia is an impairment of voluntary movement, such that it 
becomes fragmentary or incomplete. 



some of the newer antipsychotic drugs suggest that they 
may have fewer side effects than conventional 
antipsychotics such as haloperidol, but controlled 
studies are needed before firm conclusions can be 
drawn about any possible advantages in safety and 
efficacy over traditional agents. 

Disruptive Disorders 

Disruptive disorders, such as oppositional defiant 
disorder and conduct disorder, are characterized by 
antisocial behavior and, as such, seem to be a collection 
of behaviors rather than a coherent pattern of mental 
dysfunction. These behaviors are also frequently found 
in children who suffer from attention-deficit/hyper- 
activity disorder, another disruptive disorder, which is 
discussed separately in this chapter. Children who 
develop the more serious conduct disorders often show 
signs of these disorders at an earlier age. Although it is 
common for a very young children to snatch something 
they want from another child, this kind of behavior may 
herald a more generally aggressive behavior and be the 
first sign of an emerging oppositional defiant or 
conduct disorder if it occurs by the ages of 4 or 5 and 
later. However, not every oppositional defiant child 
develops conduct disorder, and the difficult behaviors 
associated with these conditions often remit. 

Oppositional defiant disorder (ODD) is diagnosed 
when a child displays a persistent or consistent pattern 
of defiance, disobedience, and hostility toward various 
authority figures including parents, teachers, and other 
adults. ODD is characterized by such problem 
behaviors as persistent fighting and arguing, being 
touchy or easily annoyed, and deliberately annoying or 
being spiteful or vindictive to other people. Children 
with ODD may repeatedly lose their temper, argue with 
adults, deliberately refuse to comply with requests or 
rules of adults, blame others for their own mistakes, 
and be repeatedly angry and resentful. Stubbornness 
and testing of limits are common. These behaviors 
cause significant difficulties with family and friends 
and at school or work (DSM-IV; Weiner, 1997). 
Oppositional defiant disorder is sometimes a precursor 
of conduct disorder (DSM-IV). 



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Children and Mental Health 



In different studies, estimates of the prevalence of 
ODD have ranged from 1 to 6 percent, depending on 
the population sample and the way the disorder was 
evaluated, but not depending on diagnostic criteria. 
Rates are lower when impairment criteria are more 
strict and when information is obtained from teachers 
and parents rather than from the children alone (Shaffer 
et al., 1996a). Before puberty, the condition is more 
common in boys, but after puberty the rates in both 
genders are equal. 

hi preschool boys, high reactivity, difficulty being 
soothed, and high motor activity may indicate risk for 
the disorder. Marital discord, disrupted child care with 
a succession of different caregivers, and inconsistent, 
unsupervised child-rearing may contribute to the 
condition. 

Children or adolescents with conduct disorder 
behave aggressively by fighting, bullying, intimidating, 
physically assaulting, sexually coercing, and/or being 
cruel to people or animals. Vandalism with deliberate 
destruction of property, for example, setting fires or 
smashing windows, is common, as are theft; truancy; 
early tobacco, alcohol, and substance use and abuse; 
and precocious sexual activity. Girls with a conduct 
disorder are prone to running away from home and may 
become involved in prostitution. The behavior 
interferes with performance at school or work, so that 
individuals with this disorder rarely perform at the level 
predicted by their IQ or age. Their relationships with 
peers and adults are often poor. They have higher 
injury rates and are prone to school expulsion and 
problems with the law. Sexually transmitted diseases 
are common. If they have been removed from home, 
they may have difficulty staying in an adoptive or 
foster family or group home, and this may further 
complicate their development. Rates of depression, 
suicidal thoughts, suicide attempts, and suicide itself 
are all higher in children diagnosed with a conduct 
disorder (Shaffer et al., 1996b). 

The prevalence of conduct disorder in 9- to 17- 
year-olds in the community varies from 1 to 4 percent, 
depending on how the disorder is defined (Shaffer et 
al., 1996a). Children with an early onset of the 
disorder, i.e., onset before age 10, are predominantly 



male. The disorder appears to be more common in 
cities than in rural areas (DSM-IV). Those with early 
onset have a worse prognosis and are at higher risk for 
adult antisocial personality disorder (DSM-IV; Rutter 
& Ciller, 1984; Hendren & Mullen, 1997). Between a 
quarter and a half of highly antisocial children become 
antisocial adults. 

The etiology of conduct disorder is not fully 
known. Studies of twins and adopted children suggest 
that conduct disorder has both biological (including 
genetic) and psychosocial components (Hendren & 
Mullen, 1997). Social risk factors for conduct disorder 
include early maternal rejection, separation from 
parents with no adequate alternative caregiver 
available, early institutionalization, family neglect, 
abuse or violence, parents' psychiatric illness, parental 
marital discord, large family size, crowding, and 
poverty (Loeber & Stouthamer-Loeber, 1986). These 
factors are thought to lead to a lack of attachment to the 
parents or to the fanuly unit and eventually to lack of 
regard for the rules and rewards of society (Sampson & 
Laub, 1993). Physical risk factors for conduct disorder 
include neurological damage caused by birth 
complications or low birthweight, attention- 
deficit/hyperactivity disorder, fearlessness and stim- 
ulation-seeking behavior, learning impairments, 
autonomic underarousal, and insensitivity to physical 
pain and punishment. A child with both social 
deprivation and any of these neurological conditions is 
most susceptible to conduct disorder (Raine et al., 
1998). 

Since many of the risk factors for conduct disorder 
emerge in the first years of life, intervention must begin 
very early. Recently, screening instruments have been 
developed to enable earlier identification of risk factors 
and signs of conduct disorder in young children (Fell et 
al., 1995). Studies have shown a correlation between 
the behavior and attributes of 3-year-olds and the 
aggressive behavior of these children at ages 11 to 13 
(Raine et al., 1998). Measurements of aggressive 
behaviors have been shown to be stable over time 
(Sampson & Laub, 1993). Training parents of high-risk 
children how to deal with the children's demands may 
help. Parents may need to be taught to reinforce 



165 



Mental Health: A Report of the Surgeon General 



appropriate behaviors and not harshly punish 
transgressing ones, and encouraged to find ways to 
increase the strength of the emotional ties between 
parent and child. Working with high-risk children on 
social interaction and providing academic help to 
reduce rates of school failure can help prevent some of 
the negative educational consequences of conduct 
disorder (Johnson & Breckenridge, 1982). 

Treatment 

Several psychosocial interventions can effectively 
reduce antisocial behavior in disruptive disorders. A 
recent review of psychosocial treatments for children 
and adolescents identified 82 studies conducted 
between 1966 and 1995 involving 5,272 youth (Brestan 
& Eyberg, 1998). The criterion for inclusion was that 
the child was in treatment for conduct problem 
behavior, based on displaying a symptom of conduct 
disorder or oppositional defiant disorder, rather than on 
a DSM diagnosis of either, although children did meet 
DSM criteria for one of these conditions in about one- 
third of the studies. 

By applying criteria established by the American 
Psychological Association Task Force (see earlier) to 
the 82 studies, two treatments met criteria for well- 
established treatment and 10 for probably ejficacious 
treatment. Two well-established treatments, both di- 
rected at training parents, succeeded in reducing 
problem behaviors. The two treatments were a parent 
training program based on the manual Living With 
Children (Bemal et al., 1980) and a videotape modeling 
parent training (Spaccarelli et al., 1992). The first 
teaches parents to reward desirable behaviors and 
ignore or punish deviant behaviors, based on principles 
of operant conditioning. The second provides a series 
of videotapes covering parent-training lessons, after 
which a therapist leads a group discussion of the 
videotape lessons. The identification of 12 treatments 
as well-established or probably ejficacious is very 
encouraging because of the potential to intervene 
effectively with youth at high risk of poor outcomes. A 
new and promising approach for the treatment of 
conduct disorder is multisystemic therapy, an intensive 



home- and family-focused treatment that is described 
under Home-Based Services. 

Despite strong enthusiasm for improving care for 
conduct-disordered youth, there are important groups of 
children, specifically girls and ethnic minority 
populations, who were not sufficiently represented in 
these studies to ensure that the identified treatments 
work for them. Other issues raised by Brestan and 
Eyberg (1998) are cost-effectiveness, the sufficiency of 
a given intervention, effectiveness over time, and the 
prevention of relapse. 

No drugs have been demonstrated to be 
consistently effective in treating conduct disorder, 
although four drugs have been tested. Lithium and 
methylphenidate have been found (one double-blind 
placebo trial each) to reduce aggressiveness effectively 
in children with conduct disorder (Campbell et al., 
1995; Klein et al., 1997b), but in two subsequent 
studies with the same design, the positive findings for 
lithium could not be reproduced (Rifkin et al., 1989; 
Klein, 1991). In one of the latter studies, methyl- 
phenidate was superior to lithium and placebo. A third 
drug, carbamazepine, was found in a pilot study to be 
effective, but multiple side effects were also reported 
(Kafantaris et al., 1992). The fourth drug, clonidine, 
was explored in an open trial, in which 15 of 17 
patients showed a significant decrease in aggressive 
behavior, but there were also significant side effects 
that would require monitoring of cardiovascular and 
blood pressure parameters (Kemph et al., 1993). 

Substance Use Disorders in Adolescents 

Since the early 1990s there has been a "sharp 
resurgence" in the misuse of alcohol and other drugs by 
adolescents (Johnston et al., 1996). A recent review, 
focusing particularly on substance abuse and 
dependence, synthesizes research findings of the past 
decade (Weinberg et al., 1998). The authors review 
epidemiology, course, etiology, treatment, and 
prevention and discuss comorbidity with other mental 
disorders in adolescents. All of these issues are 
important to public health, but none is more relevant to 
this report than the co-occurrence of alcohol and other 



166 



Children and Mental Health 



substance use disorders with other mental disorders in 
adolescents. 

According to the National Comorbidity Study, 41 
to 65 percent of individuals with a lifetime substance 
abuse disorder also have a lifetime history of at least 
one mental disorder, and about 5 1 percent of those with 
one or more lifetime mental disorders also have a 
lifetime history of at least one substance use disorder 
(Kessler et al., 1996). The rates are highest in the 15- to 
24-year-old age group (Kessler et al., 1994). The cross- 
sectional data on association do not permit any 
conclusion about causality or clinical prediction 
(Kessler et al., 1996), but an appealing theory suggests 
that a subgroup of the population abuses drugs in an 
effort to self-medicate for the co-occurring mental 
disorder. Little is actually known about the role of 
mental disorders in increasing the risk of children and 
adolescents for misuse of alcohol and other drugs. 
Stress appears to play a role in both the process of 
addiction and the development of many of the 
comorbid conditions. 

The review by Weinberg and colleagues (1998) 
provides more detail on epidemiology and assessment 
of alcohol and other drug use in adolescents and 
describes several effective treatment approaches for 
these problems. A meta-analysis and literature review 
(Stanton & Shadish, 1997) concluded that family- 
oriented therapies were superior to other treatment 
approaches and enhanced the effectiveness of other 
treatments. Multisystemic family therapy, discussed 
elsewhere in this chapter, is effective in reducing 
alcohol and other substance use and other severe 
behavioral problems among adolescents (Pickrel & 
Henggeler, 1996). 

Eating Disorders 

Eating disorders are serious, sometimes life- 
threatening, conditions that tend to be chronic (Herzog 
et al., 1999). They usually arise in adolescence and 
disproportionately affect females. About 3 percent of 
young women have one of the three main eating 
disorders: anorexia nervosa, bulimia nervosa, or binge- 
eating disorder (Becker et al., 1999). Binge-eating 
disorder is a newly recognized condition featuring 



episodic uncontrolled consumption, without 
compensatory activities, such as vomiting or laxative 
abuse, to avert weight gain (Devlin, 1996). Bulimia, in 
contrast, is marked by both binge eating and by 
compensatory activities. Anorexia nervosa is 
characterized by low body weight (< 85 percent of 
expected weight), intense fear of weight gain, and an 
inaccurate perception of body weight or shape 
(DSM-IV). Its mean age of onset is 17 years (DSM-IV). 

The causes of eating disorders are not known with 
precision but are thought to be a combination of 
genetic, neurochemical, psychodevelopmental, and 
sociocultural factors (Becker et al., 1999; Kaye et al., 
1999). Comorbid mental disorders are exceedingly 
common, but interrelationships are poorly understood. 
Comorbid disorders include affective disorders 
(especially depression), anxiety disorders, substance 
abuse, and personality disorders (Herzog et al., 1996). 
Anorexia nervosa has the most severe consequence, 
with a mortality rate of 0.56 percent per year (or 5.6 
percent per decade) (Sullivan, 1995), a rate higher than 
that of almost all other mental disorders (Herzog et al., 
1996). Mortality is from starvation, suicide, or 
electrolyte imbalance (DSM-IV). The mortality rate 
from anorexia nervosa is 12 times higher than that for 
other young women in the population (Sullivan , 1995). 

Treatment of eating disorders entails psychotherapy 
and pharmacotherapy, either alone or in combination. 
Treatment of comorbid mental disorders also is 
important, as is treatment of medical complications. 
There are some controlled studies of the efficacy of 
specific treatments for adults with bulimia and binge- 
eating disorder (Devlin, 1996), but fewer for anorexia 
nervosa (Kaye et al., 1999). Controlled studies in 
adolescents are rare for any eating disorder (Steiner and 
Lock, 1998). Pharmacological studies in young adult 
women found conflicting evidence of benefit from 
antidepressants for anorexia and some reduction in the 
frequency of binge eating and purging with tricyclic 
antidepressants, monoamine oxidase inhibitors, and 
SSRIs (see Jimerson et al., 1993; Jacobi et al., 1997). 
Studies mostly of adult women find cognitive- 
behavioral therapy and interpersonal therapy to be 
effective for bulimia and binge-eating disorder 



167 



Mental Health: A Report of the Surgeon General 



(Fairburn et al., 1993; Devlin, 1996; Becker et al, 
1999). Clearly, more research is warranted for the 
treatment of eating disorders, especially because a 
sizable proportion of those with eating disorders have 
limited response to treatment (Kaye et al., 1999). 

Services Interventions 

Treatment Interventions 

This section examines the effectiveness of such 
treatment interventions as outpatient, partial 
hospitalization/day, residential, inpatient treatments, 
and medication. Much of the research on their 
effectiveness deals with children's outcomes largely 
independent of diagnosis. As noted earlier in this 
chapter (see Treatment Strategies), practitioners and 
researchers previously shied away from diagnosis 
because of the inherent difficulty of making a 
diagnosis, concerns about labeling children, and the 
limited usefulness of DSM classifications for children. 
Each intervention was developed to treat a host of 
mental health conditions in children and adolescents. 
Each also was delivered in a wide range of settings. 
Over time, the combination of interventions and 
settings, with the exception of medication, became 
conceptualized as "treatments," which stimulated 
research on their effectiveness (Goldman, 1998). They 
are not, however, treatments in the conventional sense 
of the term because they are less specific than other 
treatments with respect to indications, intensity (i.e., 
"dose"), and elements of the intervention. There is little 
research describing treatment in actual clinical settings. 

Outpatient Treatment 

The term "outpatient treatment" covers a large variety 
of therapeutic approaches, with most falling into the 
broad theoretical categories of the psychodynamic, 
interpersonal, and behavioral psychotherapy. 
Outpatient psychotherapy is the most common form of 
treatment for children and adolescents, utilized 
annually by an estimated 5 to 10 percent of children 
and their families in the United States (Bums et al., 
1998). It is also the most extensively studied 
intervention and, with over 300 studies, has the 



strongest research base (Weisz et al., 1998). Outpatient 
therapy is offered to individuals, groups, or families, 
usually in a clinic or private office. The duration of 
treatment varies from 6 to 12 weekly sessions to a year 
or longer. Newer outpatient interventions (e.g., case 
management, home-based therapy) that were developed 
more recently for youth with severe disorders are 
provided with greater frequency (i.e., daily) in the 
home, school, or community. Those interventions are 
reviewed later in this chapter. 

The strongest support for the effectiveness of 
outpatient treatment comes from a series of meta- 
analyses. Meta-analyses are an important type of 
research methodology, described in Chapter 1, that 
enable one to combine research findings from separate 
studies. Nine meta-analyses, published between 1985 
and 1995, probed the effectiveness of research on 
individual, group, and family therapy for children and 
adolescents (Casey & Berman, 1985; Hazelrigg et al., 
1987; Weisz et al., 1987; Kazdin et al., 1990; Baer & 
Nietzel, 1991; Grossman & Hughes 1992; Shadish et 
al., 1993; Weisz & Weiss, 1993; Weisz et al., 1995). 
Although these meta-analyses vary in time period, age 
groups, and meta-analytic approach, they were largely 
restricted to studies of treatment given in a research 
clinical setting, and their findings are relatively 
consistent. The major findings indicated that the 
improvements with outpatient therapy are greater than 
those achieved without treatment; the treatment is 
highly effective, as was found in meta-analyses of 
adults (Brown, 1987); and the effects of treatment are 
similar, whether applied to problems such as anxiety, 
depression, or withdrawal (internalizing problems) or 
to hyperactivity and aggression (externalizing 
problems) (Kazdin, 1996). 

Given strong evidence of efficacy for outpatient 
treatment, the question of applicability to real-world 
settings has been examined. A meta-analysis was 
performed on studies of the effectiveness of various 
types of outpatient treatment, regardless of whether 
their efficacy had been established through research 
(Weisz et al., 1995). The researchers were able to 
identify only nine studies of treated children in 
nonresearch clinical settings where therapy was a 



168 



Children and Mental Health 



regular service of the clinic and was carried out by 
practicing clinicians. Those nine studies demonstrated 
little or no effect. Clearly, real-world therapy was 
found to be less effective than that provided through a 
research protocol. A variety of factors may account for 
the gap, including less attention in real-world settings 
to careful matching of patients with treatments, less 
adherence to a treatment protocol, and less followup 
care. 

Partial Hospitalization/Day Treatment 

Partial hospitalization, also called day treatment and 
partial care, has been a growing treatment modality for 
youth with mental disorders. Research on partial 
hospitalization as an alternative to inpatient treatment 
generally finds benefit from a structured daily 
environment that allows youth to return home at night 
to be with their family and peers. 

Partial hospitalization is a specialized and intensive 
form of treatment that is less restrictive than inpatient 
care but is more intensive than the usual types of 
outpatient care (i.e., individual, family, or group 
treatment). The most frequently used type of partial 
hospitahzation is an integrated curriculum combining 
education, counseling, and family interventions. The 
setting, be it a hospital, school, or clinic, may be tied to 
the theoretical orientation of the treatment, which 
ranges from psychoanalytic to behavioral. Partial 
hospitalization has also been used as a transitional 
service after either psychiatric hospitalization or 
residential treatment, at the point when the child no 
longer needs 24-hour care but is not ready to be 
integrated into the school system. It also is used to 
prevent institutional placement. 

Overall, the research literature points to positive 
gains from adolescent use of day treatment, but most of 
the studies are uncontrolled. Gains relate to academic 
and behavioral improvement; reduction in, or delay of, 
hospital and residential placement; and a return to 
regular school for about 75 percent of patients (Baenen 
et al., 1986; Gabel & Finn, 1986). Day treatment 
programs are not being used as frequently as they might 
be because third-party payers are reluctant to support 
this form of treatment. They claim that the modality is 



ambiguous, that it induces demand among those who 
would not otherwise seek treatment, and that its length, 
treatment outcomes, and costs are unpredictable (Kiser 
et al., 1986). Research is needed to address these 
issues. 

To date, the only controlled study of partial 
hospitalization compared outcomes for young children 
(ages 5 to 12) with disruptive behavior disorders who 
received intensive day treatment with children who 
received traditional outpatient treatment services (in 
fact, a waiting Ust control) (Grizenko et al., 1993). The 
results at 6 months favored day treatment in reducing 
behavior problems, decreasing symptoms, and improv- 
ing family functioning. 

Findings from uncontrolled studies of partial 
hospitalization are informative, although not conclu- 
sive. Based on approximately 20 studies, multiple 
benefits have been reported even over the long term 
(see reviews by Kutash & Rivera, 1996; Grizenko, 
1997). In general, child behavior and family 
functioning improve following partial hospitalization. 
Findings for improved academic achievement are 
mixed and possibly suggest that implementation of 
school-based models should be considered. About 
three-fourths of youth are reintegrated into regular 
school, often with the help of special education or other 
school- or community-based services. Several 
uncontrolled studies found that day treatment could 
prevent youth from entering other costly placements 
(particularly inpatient and residential treatment 
centers), which suggests that partial hospitalization 
may reduce overall costs of treatment (Kutash & 
Rivera, 1996). Finally, family participation during and 
following day treatment is essential to obtaining and 
maintaining results (Kutash & Rivera, 1996). 

Residential Treatment Centers 

Residential treatment centers are the second most 
restrictive form of care (next to inpatient 
hospitalization) for children with severe mental 
disorders. Although used by a relatively small 
percentage (8 percent) of treated children, nearly one- 
fourth of the national outlay on child mental health is 
spent on care in these settings (Burns et al., 1998). 



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Mental Health: A Report of the Surgeon General 



However, there is only weak evidence for their 
effectiveness. 

A residential treatment center (RTC) is a licensed 
24-hour facility (although not licensed as a hospital), 
which offers mental health treatment. The types of 
treatment vary widely; the major categories are 
psychoanalytic, psychoeducational, behavioral 
management, group therapies, medication management, 
and peer-cultural. Settings range from structured ones, 
resembling psychiatric hospitals, to those that are more 
like group homes or halfway houses. While formerly 
for long-term treatment (e.g., a year or more), RTCs 
under managed care are now serving more seriously 
disturbed youth for as briefly as 1 month for intensive 
evaluation and stabilization. 

Concerns about residential care primarily relate to 
criteria for admission; inconsistency of community- 
based treatment established in the 1980s; the costliness 
of such services (Friedman & Street, 1985); the risks of 
treatment, including failure to learn behavior needed in 
the community; the possibility of trauma associated 
with the separation from the family; difficulty 
reentering the family or even abandonment by the 
family; victimization by RTC staff; and learning of 
antisocial or bizarre behavior from intensive exposure 
to other disturbed children (Barker, 1998). These 
concerns are discussed below. 

In the past, admission to an RTC has been justified 
on the basis of community protection, child protection, 
and benefits of residential treatment per se (Barker, 
1982). However, none of these justifications have stood 
up to research scrutiny. In particular, youth who display 
seriously violent and aggressive behavior do not appear 
to improve in such settings, according to limited 
evidence (Joshi & Rosenberg, 1997). One possible 
reason is that association with deUnquent or deviant 
peers is a major risk factor for later behavior problems 
(Loeber & Harrington, 1998). Moreover, community 
interventions that target change in peer associations 
have been found to be highly effective at breaking 
contact with violent peers and reducing aggressive 
behaviors (Henggeler et al., 1998). Although removal 
from the community for a time may be necessary for 
some, there is evidence that highly targeted behavioral 



interventions provided on an outpatient basis can 
ameliorate such behaviors (Brestan & Eyberg, 1998). 
For children in the second category (i.e., those needing 
protection from themselves because of suicide attempts, 
severe substance use, abuse, or persistent running 
away), it is possible that a brief hospitalization for an 
acute crisis or intensive community-based services may 
be more appropriate than an RTC. An intensive long- 
term program such as an RTC with a high staff to child 
ratio may be of benefit to some children, especially 
when sufficient supportive services are not available in 
their communities. In short, there is a compelhng need 
to clarify criteria for admission to RTCs (Wells, 1991). 
Previous criteria have been replaced and strengthened 
(i.e., with an emphasis on resources needed after 
discharge) by the National Association of Psychiatric 
Treatment Centers for Children (1990). 

The evidence for outcomes of residential treatment 
comes from research published largely in the 1970s and 
1980s and, with three exceptions, consists of 
uncontrolled studies (see Curry, 1991). 

Of the three controlled studies of RTCs, the first 
evaluated a program called Project Re-Education (Re- 
Ed). Project Re-Ed, a model of residential treatment 
developed in the 1960s, focuses on training teacher- 
counselors, who are backed up by consultant mental 
health specialists. Project Re-Ed schools are located 
within communities, facilitating therapeutic work with 
the family and allowing the child to go home on 
weekends. Camping also is an important component of 
the program, inspired by the Outward Bound Schools 
in England. The first published study of Project Re-Ed 
compared outcomes for adolescent males in Project Re- 
Ed with untreated disturbed adolescents and with 
nondisturbed adolescents. Treated adolescents 
improved in self-esteem, control of impulsiveness, and 
internal control compared with untreated adolescents, 
according to ratings by Project Re-Ed staff and by 
families (Weinstein, 1974). A 1988 followup study of 
Project Re-Ed found that when adjustment outcomes 
were maintained at 6 months after discharge from 
Project Re-Ed, those outcomes were predicted more by 
community factors at admission (e.g., condition of the 
family and school, supportiveness of the local 



170 



Children and Mental Health 



community) than by client factors (e.g., diagnosis, 
school achievement, age, IQ). This suggested that 
interventions in the child's community might be as 
effective as placement in the treatment setting (Lewis, 
1988). 

The only other controlled study compared an RTC 
with therapeutic foster care through the Parent 
Therapist Program. Both client groups shared 
comparable backgrounds and made similar progress in 
their respective treatment program. However, the 
residential treatment cost twice as much as therapeutic 
foster care (Rubenstein et al., 1978). 

Despite strong caveats about the quality, 
sophistication, and import of uncontrolled studies, 
several consistent findings have emerged. For most 
children (60 to 80 percent), gains are reported in areas 
such as clinical status, academic skills, and peer 
relationships. Whether gains are sustained following 
treatment appears to depend on the supportiveness of 
the child's post-discharge environment (Wells, 1991). 
Several studies of single institutions report main- 
tenance of benefits from 1 to 5 years later (Blackman et 
al., 1991 ; Joshi & Rosenberg, 1997). In contrast, a large 
longitudinal six-state study of children in publicly 
funded RTCs found at the 7 -year followup that 75 
percent of youth treated at an RTC had been either 
readmitted to a mental health facility (about 45 percent) 
or incarcerated in a correctional setting (about 30 
percent) (Greenbaum et al., 1998). 

In summary, youth who are placed in RTCs clearly 
constitute a difficult population to treat effectively. The 
outcomes of not providing residential care are 
unknown. Transferring gains from a residential setting 
back into the community may be difficult without clear 
coordination between RTC staff and community 
services, particularly schools, medical care, or 
community clinics. Typically, this type of coordination 
or aftercare service is not available upon discharge. The 
research on RTCs is not very enlightening about the 
potential to substitute RTC care for other levels of care, 
as this requires comparisons with other interventions. 
Given the limitations of current research, it is 
premature to endorse the effectiveness of residential 
treatment for adolescents. Moreover, research is needed 



to identify those groups of children and adolescents for 
whom the benefits of residential care outweigh the 
potential risks. 

Inpatient Treatment 

Inpatient hospitalization is the most restrictive type of 
care in the continuum of mental health services for 
children and adolescents. Questions about excessive 
and inappropriate use of hospitals were raised in the 
early 1980s (Knitzer, 1982) and clearly documented 
thereafter in rising admission rates from the 1980s into 
the mid-1990s, without evidence of increased social or 
clinical need for such treatment (Weller et al., 1995). 
Inpatient care consumes about half of child mental 
health resources, based on the latest estimate available 
(Bums, 1991), but it is the clinical intervention with the 
weakest research support. Nevertheless, because some 
children with severe disorders do require a highly 
restrictive treatment environment, hospitals are 
expected to remain an integral component of mental 
health care (Singh et al., 1994). More concerted 
attention to the risks and benefits of hospital use is 
critical, however, along with development of 
community-based alternative services. 

Research on inpatient treatment mostly consists of 
uncontrolled studies (Curry, 1991). Factors that are 
likely to predict benefit have been identified from such 
studies. Beneficial factors were found to include higher 
child intelligence; the quality of family functioning and 
family involvement in treatment; specific 
characteristics of treatment (e.g., completion of 
treatment program and planned discharge); and the use 
of aftercare services. Neither age nor gender affected 
prognosis after hospitalization. The prognosis was poor 
for several clinical characteristics, including children 
with a psychotic diagnosis and antisocial features with 
conduct disorder (Kutash & Rivera, 1996). 

Only three controlled studies evaluated the 
effectiveness of inpatient treatment: one that random- 
ized antisocial children to specific interventions on an 
inpatient unit (Kazdin et al., 1987a, 1987b) and two 
older clinical trials (Flomenhaft, 1974; Winsberg et al., 
1980). All three studies demonstrated that community 
care was at least as effective as inpatient treatment. 



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More recently there have been preliminary 
favorable findings from a randomized trial of inpatient 
treatment versus multisystemic therapy (MST), an 
intensive home -based intervention. For example, MST 
was more effective than psychiatric hospitalization in 
reducing antisocial behavior, improving family 
structure and cohesion, improving social relationships, 
and keeping children in school and out of institutions 
(after the initial period when the control group was in 
the hospital). Hospitalized youth reported improved 
self-esteem, and youth in both treatment conditions 
showed comparable decreases in emotional distress 
(Henggeler et al., 1998). A great deal more research is 
needed on inpatient hospitalization, as it is by far the 
costliest and most restrictive form of care. Recent 
changes in health care management have resulted in 
short lengths of stay for children and adolescents. 
Preliminary results from the study of MST indicate that 
intensive home-based services may be a viable 
alternative to hospitalization. However, even when 
such services are available, there may be a need for 
brief24-hour stabilization units for handling crises (see 
Crisis Services). 

Newer Community- Based Interventions 

Since the 1980s, the field of children's mental health 
has witnessed a shift from institutional to community- 
based interventions. The forces behind this 
transformation are presented in a subsequent section. 
Service Delivery. This section attempts to answer the 
question of whether community-based interventions are 
effective. It covers a range of comprehensive 
community-based interventions, including case 
management, home-based services, therapeutic foster 
care, therapeutic group homes, and crisis services. 
Although the evidence for the benefits of some of these 
services is uneven at best, even uncontrolled studies 
offer a starting point for studying the effectiveness and 
feasibility of their implementation. Many of the 
evaluations to date offer a first glimpse into the benefits 
of these services and the extent to which they may be 
valuable for further examination. Of these inter- 
ventions, the most convincing evidence of effectiveness 



is for home-based services and therapeutic foster care, 
as discussed below. 

There is a special emphasis throughout this section 
on "children with serious emotional disturbances," as 
many of these community-based services are targeted 
to this population of the most serious severely affected 
children. The term serious emotional disturbance refers 
to a diagnosed mental health problem that substantially 
disrupts a child's ability to function socially, 
academically, and emotionally. It is not a formal 
DSM-FV diagnosis but rather a term that has been used 
both within states and at the Federal level to identify a 
population of children with significant functional 
impairment due to mental, emotional, and behavioral 
problems who have a high need for services. The 
official definition of children with serious emotional 
disturbance adopted by the Substance Abuse and 
Mental Health Services Administration is "persons 
from birth up to age 18 who currently or at any time 
during the past year had a diagnosable mental, 
behavioral, or emotional disorder of sufficient duration 
to meet diagnostic criteria specified within the DSM- 
ni-R, and that resulted in functional impairment which 
substantially interferes with or limits the child's role or 
functioning in family, school, or community activities" 
(SAMHSA, 1993, p. 29425).'^ The term is used in a 
variety of Federal statutes in reference to children 
fitting that description and does not signify any 
particular diagnosis per se; rather, it is a legal term that 
triggers a host of mandated services to meet the needs 
of these children (see Service DeUvery section). 

Case Management 

Case management is an important and widespread 
component of mental health services, especially for 
children with serious emotional disturbances. The main 
purpose of case management is to coordinate the 
provision of services for individual children and their 
families who require services from multiple service 
providers. Case managers take on roles ranging from 
brokers of services to providers of clinical services. 



'^ This definition is also used with newer diagnostic systems, such 
as DSM-IV. 



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There is a considerable amount of variation in models 
of case management. In one important model, called 
"wraparound," case managers involve families in a 
participatory process of developing an individualized 
plan focusing on individual and family strengths in 
multiple life domains. Research on wraparound is still 
in its early stages (Bums & Goldman, 1999). 

There have been controlled studies of three 
programs that used case managers who work 
individually rather than as part of an interdisciplinary 
team (discussed later). In one study of the Partner's 
Project in Oregon, case management was compared 
with "usual services," which did not include case 
management (Gratton et al., 1995). The authors found 
at 1-year followup that children in the Partner's Project 
scored significantly higher on measures of social 
competence and had received more individualized, 
comprehensive services, and a greater degree of service 
coordination. 

The second study compared the outcomes of 
intensive case management and regular case 
management for mentally ill homeless children in 
Seattle (Cauce et al., 1994). The case managers in the 
intensive condition had lower caseloads, were required 
to spend more hours supervising the youth, had flexible 
funds (for clothing, transportation, etc.) at their 
disposal, spent more hours in consultation with 
psychologists, and were of higher educational status. 
After 1 year, the study found that both groups showed 
substantial yet similar improvement in mental health 
and social adjustment. 

A model known as Children and Youth Intensive 
Case Management (CYICM) was evaluated in two 
controlled studies. The program has been described as 
an Expanded Broker Model, which means that the case 
manager, in addition to brokering services, is 
responsible for assessment, planning, linking, and 
advocating on behalf of the youth and family. Case 
managers, with caseloads of 10 children, are given 
$2,000 of flexible funds per child each year to purchase 
treatment and ancillary services (e.g., transportation 
and educational aids). In the first study, the authors 



found that children in the program spent significantly 
more days in the community between episodes of 
psychiatric hospitalization and were hospitalized for 
fewer days than before enrollment (Evans et al., 1994). 
A subsequent study evaluated a random sample of 199 
children enrolled in CYICM (Evans et al, 1996b). 
Findings at 3-year followup indicated significant 
behavioral improvements and decreases in unmet 
medical, recreational, and educational needs compared 
with findings at enrollment. As in the previous study, 
children who had been in CYICM for 2 years had spent 
fewer days in psychiatric hospitals and more days in 
community settings during the intervals between 
hospitalizations. This study went further to compare 
their hospital utilization with that by children not 
enrolled in the program. Although CYICM clients spent 
more days in psychiatric hospitals before enrollment, 
they used inpatient services after enrollment 
significantly less than did non-enrollees. CYICM 
clients' hospital admissions declined fivefold after 
enrollment whereas among non-enrollees the decline in 
admission rates was less than half that value. This 
difference translated into a savings of almost 
$8,000,000 for New York State, where the project took 
place. 

Some research has investigated the effects of 
extending case management on children with a dual 
diagnosis of a mental disorder and a substance abuse 
problem. Within the CYICM program, researchers 
looked at whether adolescents with mental disorders 
and substance abuse problems derived comparable 
benefits from the program as did those without 
substance abuse problems (Evans et al., 1992). No 
significant differences were found in the average 
number of inpatient admissions both before and after 
enrollment. There was also no significant difference 
between groups in the average decrease from pre- to 
postenrollment in the number of days spent in 
hospitals. These results indicate that case management 
can be as effective for youth presenting with substance 
abuse problems as for youth presenting with other 
psychiatric disorders. 



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Mental Health: A Report of the Surgeon General 



Team Approaches to Case Management 
Several studies assessed the value of case management 
as part of a treatment team. In a randomized trial in 
North Carolina (Bums et al., 1996), youth served by an 
interdisciplinary treatment team led by a case manager 
were compared with a control group of youth served by 
a treatment team led by their primary clinician in the 
role of case manager (also called clinician case 
manager). At 1-year followup, case managers in the 
experimental group reported spending significantly 
more time with their clients, as well as significantly 
more time on the core functions of case management 
(e.g., outreach; assessment of strengths, needs, and 
resources; service planning and monitoring; linking, 
referral, and advocacy; and crisis intervention). The 
experimental group also remained in the case-managed 
program longer, spent fewer days in psychiatric 
hospitals, and received more community-based services 
and a more comprehensive array of services. Although 
both groups showed similar clinical and functional 
improvements, parents of youth in the experimental 
group reported more satisfaction with the service 
system. The study concluded that traditional case 
managers, rather than clinician case managers, provide 
a more cost-effective method for attaining positive 
behavioral outcomes and access to mental health 
services. 

Another example of a team approach to case 
management is the Family Centered Intensive Case 
Management (FCICM) program. This was originally 
created as a variation of Child and Youth Intensive 
Case Management in New York, with the later addition 
of a wraparound approach. The wraparound approach 
is based on a belief that the child and family should be 
placed at the center of an array of coordinated health 
and mental health, educational, and other social welfare 
services and resources, which a case manager wraps 
around the patient and family. In a randomized trial, 
children were assigned to either FCICM or Family- 
Based Treatment (Evans et al., 1996a). Family-Based 
Treatment included training, support, and respite care 
for foster families but did not include case managers. 



The findings at 18 months (or at discharge) indicated 
that children in FCICM had significantly fewer 
behavioral symptoms and significantly greater 
improvements in overall functioning than those in 
Family-Based Treatment. In addition, the average 
annual cost of FCICM was less than half that of 
Family-Based Treatment. 

The Fostering Individualized Assistance Program 
(FIAP) is an example of case management provided 
through a wraparound approach. The effectiveness of 
this model, which used clinical case managers, was 
compared with standard foster care in a randomized 
trial involving 131 children and their families (Clark et 
al., 1998). The most important duty of the FIAP case 
managers was to arrange monthly team meetings for the 
monitoring of individualized service plans. Although 
both groups showed significant improvement in their 
behavioral adjustment over a 3!/2-year period, children 
in the FIAP group were less hkely to change 
placements, and boys in the group reported better social 
adjustment and fewer delinquencies. Older youth in the 
group were more hkely to maintain placements in 
homes of relatives and less likely to run away. Youth in 
FIAP were also absent from school less often and spent 
fewer days suspended from school. Overall, youth in 
the FIAP group showed more improvement than did 
youth in standard foster care. Multiple uncontrolled 
studies of case management using a wraparound 
approach were summarized in a recent monograph 
focusing on the wraparound process (Bums & 
Goldman, 1999). Overall, the reviewed studies, 
although using uncontrolled methods, offer emerging 
evidence of the potential effectiveness of case 
management using a wraparound process. 

While evidence is limited and many of the positive 
outcomes focus on service use rather than clinical 
status, there is some indication that case management 
is an effective intervention for youth with serious 
emotional disturbances. Studies in this area are difficult 
to conduct because of resource hmitations and of 
varying approaches to case management. Agreement on 
standards for specific case management models is 



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Children and Mental Health 



needed in order to proceed with efficient and reliable 
controlled research in this area. In addition, future 
research needs to address the issue of cost- 
effectiveness, as some evidence presented above has 
shown savings fromless utiUzation of institutional care. 

Home-Based Services 

This section describes the strong record of 
effectiveness for home -based services, which provide 
very intensive services within the homes of children 
and youth with serious emotional disturbances. A major 
goal is to prevent an out-of-home placement (i.e., in 
foster care, residential, or inpatient treatment). Home- 
based services are usually provided through the child 
welfare, juvenile justice, and/or mental health systems. 
They are also referred to as in-home services, family 
preservation services, family-centered services, family- 
based services, or intensive family services. 

Stroul (1988) identified three major goals of home- 
based services: to preserve the family's integrity and 
prevent unnecessary out-of-home placements; to put 
adolescents and their families in touch with community 
agencies and individuals, thus creating an outside 
support system; and to strengthen the family's coping 
skills and capacity to function effectively in the 
community after crisis treatment is completed. The 
specific services provided most often include 
evaluation, assessment, counseling, skills training, and 
coordination of services. The historical evolution of 
home-based services is discussed further under Support 
and Assistance for Families in Service Delivery. 

The evidence for the benefits of home -based 
services was recently evaluated in a meta-analysis of 
controlled studies only (Fraser et al., 1997). The 
analysis referred to home-based services as "family 
preservation services"; these were sponsored either by 
the child welfare or juvenile justice systems. For 22 
studies the authors analyzed specific measures such as 
out-of-home placement, family reunification, arrest, 
incarceration, and hospitalization, with the control 
group defined as youth receiving "usual" or "routine" 
services. While a majority of the studies demonstrated 
marginal gains in effectiveness, other services appeared 
to be significantly more effective than usual services. 



The findings are presented below according to their 
organizational sponsorship by either child welfare or 
juvenile justice system. 

Family Preservation Programs Under the Child 
Welfare System 

Within the child welfare system, particularly effective 
family reunification programs were the Homebuilders 
Program in Tacoma, Washington, which was designed 
to reunify abused and neglected children with their 
families by providing family-based services (Fraser et 
al., 1996), and the family reunification programs in 
Washington State and in Utah (Pecora et al., 1991). 
Studies suggested that 75 to 90 percent of the children 
and adolescents who participated in such programs 
subsequently did not require placement outside the 
home. The youths' verbal and physical aggression 
decreased, and cost of services was reduced (Hinckley 
& Ellis, 1985). The success of these family 
preservation programs is based on the following: 
services are delivered in a home and community 
setting; family members are viewed as colleagues in 
defining a service plan; back-up services are available 
24 hours a day; skills are built according to the 
individual needs of family members; marital and family 
interventions are offered; community services are 
efficiently coordinated; and assistance with basic needs 
such as food, housing, and clothing is given (Fraser et 
al., 1997). 

Multisystemic Therapy 

Multisystemic therapy programs within the juvenile 
justice system have demonstrated effectiveness. MST 
is an intensive, short-term, home- and family-focused 
treatment approach for youth with severe emotional 
disturbances. MST was originally based on risk factors 
that were identified in the published literature and was 
designed for delinquents. MST intervenes directly in 
the youth's family, peer group, school, and 
neighborhood by identifying and targeting factors that 
contribute to the youth's problem behaviors. The main 
goal of MST is to develop skills in both parents and 
community organizations affecting the youth that will 
endure after brief (3 to 4 months) and intensive 



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Mental Health: A Report of the Surgeon General 



treatment. MST was constructed around a set of 
principles that were put into practice and then 
expanded upon in a manual (Henggeler et al., 1998). 
Elaborate training, supervision, and monitoring for 
treatment adherence make this an exemplary approach. 
Furthermore, publication of an MST manual and the 
high level of clinical training in MST distinguish this 
model from other types of family preservation services. 
The efficacy of MST has been established in three 
randomized clinical trials for delinquents within the 
juvenile justice system. The first of these studies took 
place in Memphis, Tennessee, and revealed that MST 
was more effective than usual community services in 
decreasing adolescent behavioral problems and in 
improving family relations (Henggeler et al., 1986). 
The second was conducted in Simpsonville, South 
Carolina, and compared outcomes for 84 juvenile 
offenders randomly assigned to either MST or usual 
services. At 59 weeks after referral, youth who had 
received MST had fewer arrests and self-reported 
offenses and had spent an average of 10 fewer weeks 
incarcerated than did the youth in usual services. In 
addition, families served by MST reported increased 
family cohesion and decreased youth aggression in peer 
relations (Henggeler et al., 1992). In the third study, 
MST was compared with individual therapy in 
Columbia, Missouri, and was found to be more 
effective in ameliorating adjustment problems in 
individual family members. A 4-year folio wup of 
rearrest data indicated that MST was more effective 
than individual therapy in preventing future criminal 
behavior, including violent offenses (Borduin et al., 
1995). Studies found improved behavior, fewer arrests, 
and lower costs. These findings encouraged the 
investigators to test the effectiveness of MST in other 
organizational settings (e.g., child welfare and mental 
health), allowing them to target other clinical 
populations, including youthful sex offenders (Borduin 
et al., 1990), abused and neglected youth (Brunk et al., 
1987), and child psychiatric inpatients (see Inpatient 
Treatment section). Initial results are promising for 
youth receiving MST instead of psychiatric 
hospitahzations (Henggeler et al., 1998). As expected, 
some adjustments to MST are required to handle 



children who are dangerous to themselves and who do 
not respond as quickly to treatment as the delinquent 
youth in previous studies. The efficacy of MST was 
demonstrated in real-world settings but only by one 
group of investigators; thus, the results need to be 
reproduced by others and future effectiveness research 
needs to determine whether the same benefits can be 
demonstrated with less support from experts. 

Therapeutic Foster Care 

Therapeutic foster care is considered the least 
restrictive form of out-of-home therapeutic placement 
for children with severe emotional disorders. Care is 
delivered in private homes with specially trained foster 
parents. The combination of family-based care with 
specialized treatment interventions creates "a 
therapeutic environment in the context of a nurturant 
family home" (Stroul & Friedman, 1988). These 
programs, which are often funded jointly by child 
welfare and mental health agencies, are responsible for 
arranging for foster parent training and oversight. 
Although the research base is modest compared with 
other widely used interventions, some studies have 
reported positive outcomes, mostly related to 
behavioral improvements and movement to even less 
restrictive living environments, such as traditional 
foster care or in-home placement. 

While therapeutic foster care programs vary 
considerably, they have some features in common. 
Children are placed with foster parents who are trained 
to work with children with special needs. Usually, each 
foster home takes one child at a time, and caseloads of 
supervisors in agencies overseeing the program remain 
small. In addition, therapeutic foster parents are given 
a higher stipend than that given to traditional foster 
parents, and they receive extensive preservice training 
and in-service supervision and support. Frequent 
contact between case managers or care coordinators 
and the treatment family is expected, and additional 
resources and traditional mental health services may be 
provided as needed. 

Therapeutic foster care programs are inexpensive 
to start (few requirements for facilities or salaried staff) 
and have lower costs than more restrictive programs. In 



176 



Children and Mental Health 



Ontario, a study found that therapeutic foster care cost 
half that of residential treatment center placement for 
the same period of time (Rubenstein et al., 1978). 

There have been four efficacy studies, each with 
randomized, controlled designs, hi the first study, 20 
youths who had been previously hospitalized were 
assigned to either therapeutic foster care or other out- 
of-hospital settings, such as residential treatment 
centers or homes of relatives. The youths in therapeutic 
foster care showed more improvements in behavior and 
lower rates of reinstitutionalization, and the costs were 
lower than those in other settings (Chamberlain & 
Reid, 1991). hi another study, which concentrated on 
youths with histories of chronic delinquency, those in 
therapeutic foster care were incarcerated less frequently 
and for fewer days per episode than youths in other 
residential placements. Thus, at 2-year followup, 44 
percent fewer children in therapeutic foster care were 
incarcerated (Chamberlain & Weinrott, 1990). hi a 
third study, outcomes for children in therapeutic foster 
care were compared with those of children in standard 
foster care. Children in therapeutic foster care were less 
likely during a 2-year study to run away or to be 
incarcerated and showed greater emotional and 
behavioral adjustment (Clark et al., 1994). In the most 
recent study, therapeutic foster care was compared with 
group care: children receiving the former showed 
significantly fewer criminal referrals, returned to live 
with relatives more often, ran away less often, and were 
confined to detention or training schools less often 
(Chamberiain & Reid, 1998). 

All four studies of treatment effectiveness showed 
that youths in therapeutic foster care made significant 
improvements in adjustment, self-esteem, sense of 
identity, and aggressive behavior. In addition, gains 
were sustained for some time after leaving the 
therapeutic foster home (Bogart, 1988; Hawkins et al., 
1989; Chamberiain & Reid, 1991). 

There are also promising indications from 
uncontrolled studies. Looking at 18 reports from 12 
therapeutic foster care programs across the country, 
Kutash and Rivera (1996) concluded that between 
about 60 and 90 percent of youth treated in therapeutic 
foster homes are discharged to less restrictive settings. 



Three programs also reported followup data, indicating 
that about 70 percent of youth treated in therapeutic 
foster homes remained in less restrictive settings for a 
substantial amount of time after treatment. 

It is clear from these studies that therapeutic foster 
care produces better outcomes at lower costs than more 
restrictive types of placement. Furthermore, with the 
fairly recent development of standards for therapeutic 
foster care, as well as a standards review instrument 
(Foster Family-Based Treatment Association, 1995), 
services can be monitored for quality and fidelity to the 
therapeutic approach, making it easier to ascertain if 
the approach taken produces the favorable outcomes. 

Therapeutic Group Homes 

For adolescents with serious emotional disturbances the 
therapeutic group home provides an environment 
conducive to learning social and psychological skills. 
This intervention is provided by specially trained staff 
in homes located in the community, where local 
schools can be attended. Each home typically serves 5 
to 10 clients and provides an array of therapeutic 
interventions. Although the types and combinations of 
treatment vary, individual psychotherapy, group 
therapy, and behavior modification are usually 
included. 

There are two major models of therapeutic group 
homes. The first is the teaching family model, 
developed at the University of Kansas, then moved to 
Boys Town in Omaha, Nebraska (Phillips et al., 1974). 
The second is the Charley model, developed at the 
Menninger Clinic. Both models use their staff as the 
key agents for change in the disturbed youth; selection 
and training of the staff are emphasized. Both models 
employ couples who live at the homes 24 hours a day. 
The teaching family model emphasizes structured 
behavioral interventions through teaching new skills 
and positively reinforcing improved behavior. Other 
group homes use individual psychotherapy and group 
interaction. 

There is a dearth of research on the effectiveness of 
therapeutic group home programs targeted toward 
emotionally disturbed adolescents. These homes have 
been developed primarily for children under the care of 



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Mental Health: A Report of the Surgeon General 



juvenile justice or social welfare. A dissertation 
(Roose, 1987) studied the outcomes of 20 adolescents 
treated in a group home. Adolescents with severe 
character pathology or major psychiatric disorders were 
not admitted. Twenty group home adolescents were 
compared with 20 untreated adolescents. At an 18- 
month followup, 90 percent of the treated group had 
fair or good functioning, defined by improved 
relationships with parents, peers, and fellow workers. 
Only 45 percent of the untreated group achieved similar 
functioning. The treated group experienced a 
significant decrease in psychopathology, while the 
untreated group did not. 

Therapeutic group homes were compared with 
therapeutic foster care in two studies. The first study 
found equivalent gains for youth in the two 
interventions, but group home placement was twice as 
costly as therapeutic foster care (Rubenstein et al., 
1978). A second study, a randomized clinical trial, 
compared the outcomes for 79 males with histories of 
juvenile delinquency placed in either group homes or 
therapeutic foster homes (Chamberlain & Reid, 1998). 
The boys treated in therapeutic foster homes had 
significantly fewer criminal referrals and returned more 
often to live with relatives, suggesting this to be a more 
effective intervention. The implication of these studies 
is that if therapeutic foster care is available, and if the 
foster parents are willing to take youth with serious 
behavioral problems, therapeutic foster care may be a 
better treatment choice for youth who previously would 
have been placed in group homes. 

Existing research suggests that therapeutic group 
home programs produce positive gains in adolescents 
while they are in the home, but the limited research 
available reveals that these changes are seldom 
maintained after discharge (Kirigin et al., 1982). The 
conclusion may be similar to that for residential 
treatment center placement: long-term outcomes appear 
to be related to the extent of services and support after 
discharge. Adolescents who have been placed in 
therapeutic group homes because of mental disorders 
frequently have histories of multiple prior placements 
(particularly in foster homes), a situation that is 
associated with a poor prognosis. Thus, future 



programs would benefit from assessing alternative 
strategies for treatment after discharge from group 
homes. 

Crisis Services 

Crisis services are used in emergency situations either 
to furnish immediate and sufficient care or to serve as 
a transition to longer term care within the mental health 
system. These services are extremely important because 
many youth enter the mental health service system at a 
point of crisis. Crisis services include three basic 
components: (1) evaluation and assessment, (2) crisis 
intervention and stabilization, and (3) followup 
planning. The goals of crisis services include 
intervening immediately, providing brief and intensive 
treatment, involving families in treatment, linking 
clients and families with other community support 
services, and averting visits to the emergency 
department or hospitalization by stabilizing the crisis 
situation in the most normal setting for the adolescent. 
Crisis services include telephone hotlines, crisis group 
homes, walk-in crisis intervention services, runaway 
shelters, mobile crisis teams, and therapeutic foster 
homes when used for short-term crisis placements. 

Crisis programs are small in order to facilitate close 
relationships among the staff, child, and family. Crisis 
staff are required to have skills and experience in the 
areas of assessment, emergency treatment, and family 
support. Short-term services are provided, with the staff 
meeting more frequently with the client at the outset of 
the crisis. A typical treatment plan consists of 10 
sessions over a period of 4 to 6 weeks. Crisis services 
usually are available 24 hours a day, 7 days a week 
(Goldman, 1988). 

Research on crisis services consists exclusively of 
uncontrolled studies. Kutash and Rivera (1996) 
reviewed 12 studies with pre-post'^ designs. Positive 
behavioral and adjustment outcomes for youth 
presenting to crisis programs and emergency 
departments across the country were reported in all of 



"' Pre-post design: a research design in which a measure is 
compared on the same individual research subjects before and after 
an intervention. 



178 



Children and Mental Health 



the studies. Most programs also demonstrated the 
capacity to prevent institutionalization. 

The most recent studies examine three different 
models: a mobile crisis team, short-term residential 
services, and intensive in-home service. The first study 
examined the Youth Emergency Services (YES) 
program in New York. This program included a mobile 
crisis team that sent clinicians directly to the scene of 
the crisis. The data showed that YES prevented 
emergency department visits and out-of-home 
placements (Shulman & Athey, 1993). 

A second crisis program, in Suffolk County, New 
York, involved short-term residential services. In a 
study of 100 children served by the program over a 2- 
year period, more than 80 percent were discharged in 
less than 15 days. Most were diverted from inpatient 
hospitalization, and inpatient admissions to the state 
children's psychiatric center for Suffolk County were 
reduced by 20 percent after the program was 
established (Schweitzer & Dubey, 1994). 

In the third study, records were analyzed from a 
large sample of youth (nearly 700) presenting to the 
Home Based Crisis Intervention (HBCI) program in 
New York over a 4-year period. Youth received short- 
term, intensive, in-home emergency services. After an 
average service episode of 36 days, 95 percent of the 
youth were referred to, or enrolled in, other services 
(Boothroyd et al., 1995). The HBCI program was 
established at eight locations across the State of New 
York. Overall, programs with more access to 
community resources reported shorter average lengths 
of services. 

Although crisis and emergency services represent 
a promising intervention, the research done so far only 
includes uncontrolled studies, limiting the conclusions 
that can be drawn. Kutash and Rivera (1996) 
recommend additional effectiveness research using 
controlled study designs and comparing differences 
between the various types of crisis services. Finally, 
there remains a need for investigation of cost- 
effectiveness as well as an exploration of the 
integration of crisis services into systems of care. 



Service Delivery 

The focus of this section is on service systems — their 
origins, nature, and financing and also their 
effectiveness, delivery, and utilization — rather than on 
individual interventions and treatments, which were 
covered in previous sections of this chapter. 

About 20 years ago it became clear that children 
and families were failing to receive adequate care from 
the public sector, whose services were fragmented, 
inadequate, and overreliant on institutional care. As a 
result, the emphasis of service delivery has shifted to 
systems of care that are designed to provide culturally 
competent, coordinated services; community -based 
services; new financing arrangements in the private and 
public sectors; family participation in decisionmaking 
about care for their children; and individualized care 
drawing on treatment and social supports called 
wraparound services, described above. Thus, there has 
been progress in transforming the nature of service 
delivery and its financing, but the central question of 
the effectiveness of systems of care has not yet been 
resolved. 

At the outset, it is important to note that while 
systems of care are designed to provide the appropriate 
level of services for all children, it is children with 
serious emotional disturbances, particularly children 
who are involved in multiple service sectors, who are 
likely to benefit the most. There are approximately 6 
million to 9 million children and adolescents in the 
United States with serious emotional disturbances 
(Friedman et al., 1996a; Lavigne et al, 1996), 
accounting for 9 to 13 percent of all children (Friedman 
et al., 1996a; Friedman et al., 1998). 

The system for delivering mental health services to 
children and their families is complex, sometimes to the 
point of inscrutability — a patchwork of providers, 
interventions, and payers. Much of the complexity 
stems from the multiple pathways into treatment and 
the multiple funding streams for services. However, 
once care has begun, the interventions and settings 
themselves are generally the same as those covered in 
previous sections of this chapter. 



179 



Mental Health: A Report of the Surgeon General 



Service Utilization 

This section presents research findings about the 
utilization of mental health services by children and 
adolescents. The foremost finding is that most children 
in need of mental health services do not get them. 
Another finding refutes the common perception that 
children who do not need specialty mental health 
services are more likely to receive such services than 
those who really do need them. This section also 
discusses children's high dropout rates from treatment 
and the significance of this problem for children of 
different cultural backgrounds. 

Utilization in Relation to Need 

The conclusion that a high proportion of young people 
with a diagnosable mental disorder do not receive any 
mental health services at all (Bums et al., 1995; Leaf et 
al., 1996) reinforces an earlier report by the U.S. Office 
of Technology Assessment ( 1 986), which indicated that 
approximately 70 percent of children and adolescents 
in need of treatment do not receive mental health 
services. Only one in five children with a serious 
emotional disturbance used mental health specialty 
services, although twice as many such children 
received some form of mental health intervention 
(Bums et al., 1995). Thus, about 75 to 80 percent fail to 
receive specialty services, and the majority of these 
children fail to receive any services at all, as reported 
by their families. The most likely reasons for 
undemtilization relate to the perceptions that treatments 
are not relevant or are too demanding or that stigma is 
associated with mental health services; the reluctance 
of parents and children to seek treatment; 
dissatisfaction with services; and the cost of treatment 
(Pavuluri et al., 1996; Kazdin et al., 1997). 

Studies do, however, demonstrate a clear and 
strong relationship between use of services and 
presence of a diagnosis and/or presence of impaired 
functioning. In the study by Leaf and colleagues 
(1996), young people with both a diagnosis and 
impaired functioning were 6.8 times more likely to see 
a specialist than were those with no diagnosis and a 
higher level of functioning. 



The study by Burns and colleagues also showed 
where children were receiving treatment. Of those who 
received services and had both a diagnosis and 
impaired functioning, about 40 percent received 
services in the specialty mental health sector, about 70 
percent received services from the schools, about 1 1 
percent from the health sector, about 16 percent from 
the child welfare sector, and about 4 percent from the 
juvenile justice sector. For nearly half the children with 
serious emotional disturbances who received services, 
the public school system was the sole provider (Bums 
et al., 1995). After reviewing these findings and the 
findings from other studies, Hoagwood and Erwin 
(1997) also concluded that schools were the primary 
providers of mental health services for children. 

Early Termination of Treatment 

Among children and adolescents who begin treatment, 
the dropout rate is high, although estimates vary 
considerably. According to Kazdin and colleagues 
(1997), 40 to 60 percent of families who begin 
treatment terminate it prematurely. Armbruster and 
Fallon (1994) found that the great majority of children 
who enter outpatient treatment attend for only one or 
two sessions. One of the explanations for the high 
dropout rate and for failure to keep the first 
appointment is that referrals are often made not by 
children and adolescents or their families, but by 
schools, courts, or other agencies. Most of the research 
on dropping out has focused exclusively on examining 
demographic or diagnostic correlates of dropping out, 
and few researchers have directly asked the children or 
their parents about their reasons for discontinuing 
treatment. 

There are a number of effective interventions to 
reduce dropout from treatment and to increase 
enrollment and retention (Szapocznik et al., 1988; 
McKay et al., 1996; Santisteban et al., 1996). Offering 
services in the schools improves treatment access 
(Catron & Weiss, 1994). A variety of case management 
approaches can also improve engagement of low- 
income families in the treatment of their children 
(Bums et al., 1996; Koroloff et al., 1996a; Lambert & 
Guthrie, 1996). 



180 



Children and Mental Health 



Poverty and Utilization 

Poverty status has been associated with both dropping 
out of services and shorter lengths of treatment 
(Hoberman, 1992). This relationship between 
underutilization of mental health services and poverty 
is especially significant for minority children and 
families. Youths receiving community mental health 
services supported by public agencies tend to be male, 
poor, and referred by social agencies (Canino et al., 
1986; Costello & Janiszewski, 1990). Furthermore, 
investigators have found this pattern particularly true 
for African Americans as compared with Caucasians. 
Hoberman (1992) has found that 90 percent of African 
American youths entering the mental health system live 
in poverty. 

Culture and Utilization 

Although it is clear that an insufficient number of 
children receive mental health services, it is not clear 
whether utilization of services varies by race or 
ethnicity. The majority of studies have found that 
African Americans tend to use some mental health 
services, particularly inpatient care, more than would 
be expected from their proportion in the population. 
However, research findings are conflicting, probably 
due to divergent methodological approaches ( Attkisson 
et al., 1995; McCabe et al., 1998; Quinn & Epstein, 
1998). Furthermore, as Attkisson and colleagues (1995) 
point out, consistent with the study by McCabe and 
colleagues (1998), it is difficult to interpret these 
findings in the absence of epidemiologic data on the 
prevalence of a mental disorder in different racial and 
ethnic groups. Recent reviews of epidemiological 
findings concluded that present data are inadequate to 
determine the relationship between race or ethnicity 
and prevalence of a mental disorder (Friedman et al., 
1996b; Roberts et al, 1998). 

The task of understanding treatment patterns is 
made even more difficult because there are racial and 
ethnic differences in family preferences and family- 
initiated patterns of help-seeking (see also Culturally 
Appropriate Social Support Services). For example, 
parents from various cultural backgrounds have been 
found to differ in the degree to which they identify 



child behavioral and emotional problems as disturbed 
(Weisz & Weiss, 1991). Differences also have been 
found across cultural groups in their beliefs about 
whether these child problems are likely to improve in 
the absence of professional support. Weisz and Weiss 
(1991) have also identified cultural differences in the 
power of various children's behavioral and emotional 
problems to motivate a parent's search for professional 
help. 

Differences also arise indirectly from the 
multiplicity of service systems with authority and 
responsibility for protecting the well-being of children. 
These systems have different criteria for initiating 
treatment and different patterns of utilization. African 
American children and youth are considerably more 
likely than those of other ethnic groups to enter the 
child welfare system (National Research Council, 
1993). Their greater chances of having parents 
compelled to surrender them or of suffering abuse or 
neglect lead them in greater numbers to be referred to 
child welfare authorities, to be placed out-of-home, and 
to be involved with the child welfare system longer. 
Studies in one California county have found that 
African American youths are overrepresented in 
arrests, detention, and incarceration in the juvenile 
justice system, and in the schools they are 
overrepresented in educational classes for the severely 
emotionally disturbed. Hispanic/Latino children and 
youths are no more likely than whites to come under 
supervision of the child welfare system but, once 
involved, remain longer. They are also more likely than 
whites to be detained in juvenile justice facilities 
(McCabe et al., 1998). 

As a group, Hispanic/Latino and African American 
children more often leave mental health services 
prematurely than do Caucasian children (Sue et al., 
1991; Bui & Takeuchi, 1992; Takeuchi et al., 1993; 
Viale-Val et al., 1984). Many factors contribute to 
premature termination, such as insensitivity of mental 
health providers to the culture of children and families 
(Woodward et al., 1992). hi general, even after 
demonstrated success with middle-class Caucasians, 
mental health treatments should not be applied without 



181 



Mental Health: A Report of the Surgeon General 



culturally appropriate modification to people from 
other cultures and races (Rosado & Elias, 1993). 

Specialized programs and supports linked with the 
culture of the community being served have been found 
to be successful in promoting favorable patterns of 
service utilization for all ages (Snowden & Hu, 1997). 
It is becoming clear that the children and families 
served by mental health programs designed to be linked 
to community cultures are less likely to drop out of 
treatment compared with similar families in mainstream 
programs (Takeuchi et al., 1995). For example, Asian 
American children at an Asian community- or culture- 
focused program were found to use more services, drop 
out less often, and improve more than did Asian 
American children at mainstream programs ( Yeh et al., 
1994). 

In summarizing the relationship between race and 
ethnicity, need for service, and use of service, Isaacs- 
Shockley and colleagues (1996) raised the concern that 
minority children are less likely to receive the care they 
need than nonminority children — a concern that should 
energize advocacy for the development of systems of 
care tailored to the needs of distinct cultures (Cross et 
al., 1989; Hernandez & Isaacs, 1998). 

Service Systems and Financing 

In the past, mental health services paid for by the 
private sector were viewed as separate entities from 
those funded by the public sector, particularly since the 
public sector only paid for services that it itself 
delivered. As this section explains below, the 
distinction between public and private sectors has been 
blurred by the advent of publicly supported payment 
systems such as Medicaid and grants of public funds to 
private organizations and providers. Now in the public 
sector, services are paid for with governmental 
resources but delivered either by public or private 
organizations in institutional or community-based 
settings. 

Private Sector 

The private sector uses a health insurance model that 
reimburses for acute medical problems. Under this 
traditional model, mental health coverage usually 



entails outpatient counseling, medication treatments, 
and short-term inpatient hospitalization. Under more 
generous insurance plans, including some managed 
care plans, intermediate services, such as crisis respite 
and day hospitalization (also called partial 
hospitalization or day treatment), are becoming more 
popular although more traditional insurance plans 
continue to restrict their use. The drive to reduce the 
cost of inpatient care is sparking an expansion in the 
range of services supported by the private sector. 

When children and adolescents have complex and 
long-term mental health problems, required services are 
not usually covered by private sector insurance plans. 
Families must either pay for the services themselves or 
obtain the services through the public sector. In many 
states, parents are forced to give up custody of their 
children to the state child welfare system in order to 
obtain needed residential services (Cohen et al., 1991). 
This unfortunate choice results from a limited supply of 
public sector services and special requirements for 
gaining access to them. 

Over the past decade, managed care has become a 
major payer for private health care. Managed care 
provision of mental health services emerged partially in 
response to the overutilization of costly inpatient 
hospitalization by adolescents in the 1980s (Lourie et 
al., 1996). The purpose of managed care has been to 
control spiraling mental health service costs, mostly by 
limiting hospital stays and rigorously managing 
outpatient service usage (Stroul et al., 1998). Managed 
care can offer advantages in terms of cost-effective 
services to meet the needs of children with flexible 
benefits. It may also lead to denial of needed treatment. 
While its potential negative effect on the efficacy of 
mental health care delivered under its aegis is a hotly 
debated issue, for the most part managed care furnishes 
the same traditional services available under fee-for- 
service insurance. The drive for efficiency, however, 
has led to the introduction of intermediate services 
designed to divert children from hospitalization. 
Managed care has shortened hospital stays and 
increased the use of short-term therapy models (Eisen 
et al., 1995; Merrick, 1998). Managed care also has 
lowered reimbursements for services provided by both 



182 



Children and Mental Health 



individual professionals and institutions. This has been 
accompanied by the construction of provider networks, 
under which professionals and institutions agree to 
accept lower than customary fees as a tradeoff for 
access to patients in the network. 

Public Sector 

Mental health services provided by the public sector are 
more wide-ranging than those supported by the private 
sector, and the types of payers are more diverse. Some 
public agencies, such as Medicaid and state and local 
departments of mental health, are mandated to support 
mental health services. Others provide mental health 
services to satisfy mandates in special education, 
juvenile justice, and child welfare, among others. 

Medicaid is a major source of funding for mental 
health and related support services. For the most part, 
Medicaid has supported the traditional mix of 
outpatient and inpatient services. However, unlike 
private sector insurance, Medicaid also funds long-term 
services for those children who need more intensive or 
restrictive services, often through hospitalizations and 
residential treatments. Some states cover in-home 
services, school-based services, and case management 
through a variety of Medicaid options. Medicaid also 
supports the Early Periodic Screening, Diagnosis, and 
Treatment (EPSDT) program. 

Trapped between the private and public sectors is 
a group of uninsured individuals and families who do 
not qualify for the public sector programs, cannot 
afford to pay for services themselves, and have no 
access to private health insurance. The American 
Academy of Pediatrics estimates that in 1999 there will 
be 1 1 million uninsured children, about 3 million of 
whom do not qualify for existing public programs 
(American Academy of Pediatrics website 
www.aap.org). State and local mental health authorities 
fund some mental health services for these children, 
often offered through the same community mental 
health centers that are funded by Medicaid. Mental 
health departments in some jurisdictions also fund a 
broader array of mental health services than the 
traditional acute service package. These "intermediate" 
services include intensive case management with and 



without individualized wraparound provisions, early 
intervention programs, crisis stabilization, in-home 
therapy, and day programs. Since there has never been 
a mandate to states to provide mental health services to 
children and adolescents, the state or local support for 
such services has been variable. Thus, one might find 
a well-supported, innovative array of mental health 
services for children in one state or community, and 
almost no services in the next. The new State Child 
Health Insurance Program (CHIP) is an attempt by 
Congress to address the health care needs of low- 
income, uninsured children. States have great flexibility 
in their approach to coverage, and it remains to be seen 
how they will deal with mental health services. 

States and communities have sweeping mandates to 
serve children and adolescents in schools and under 
child welfare and juvenile service auspices. Many of 
these state and community programs, however, lack the 
expertise to recognize, refer, or treat mental health 
problems that trigger mandated services. When they do 
recognize problems, some of the needed mental health 
services are paid for by Medicaid, by the federal 
Maternal and Child Block Grant, or by a state or local 
mental health authority; often, however, they are not. 
Under these circumstances, the school, welfare, or 
juvenile justice agency ends up paying the bill for the 
mental health services. 

Under the Federal special education law, the 
Individuals with Disabilities Education Act'^ (IDEA; 
see also New Roles for Families in Systems of Care), 
school systems are mandated to provide special 
education services to children and adolescents whose 
disabilities interfere with their education. When these 
disabilities take the form of serious emotional or 
behavioral disturbances, school systems are required to 
respond through assessment, counseling, behavior 
management, and special classes or schools. When 
school systems lack sufficient capacity to meet such 
needs directly, school funds are used to send children 
and youths to specialized private day schools or to 
long-term residential schools, even if such schools are 
out of the child's state or community. In this way, 

" Public Law 94-142; Public Law 101-476; Public Law 105-17. 



183 



Mental Health: A Report of the Surgeon General 



school systems support an extensive array of mental 
health services in the public and private sectors. 

Preschool children with developmental and 
emotional disabilities are covered by some state and 
local legislation. Services for them also are mandated 
under IDEA. Whereas some states coordinate this 
education-based mandate through school systems, 
others administer the preschool programs through 
mental health or developmental disability agencies, an 
interagency coordinating body, or other state agency. 

Child welfare agencies in states and communities 
also have powerful mandates to protect children and to 
ensure that they receive the services they need, 
including mental health services. Child welfare 
agencies primarily serve poor children who are 
separated from their parents because they are orphaned, 
abandoned, abused, or neglected. Although many 
mental health services are provided either under 
Medicaid or through state and locally supported 
community mental health centers, many are not and are 
paid for directly by child welfare agencies. This 
happens most often when children and adolescents have 
severe, complicated conditions. As with education 
agencies, when funding is not available through 
Medicaid or other mental health funds, child welfare 
agencies directly pay for group home care, therapeutic 
foster care, or residential treatment. 

The same is true for juvenile justice agencies, 
which have strong mandates to protect children and the 
public. Many children and adolescents in the juvenile 
justice system have serious mental health problems. 
Beyond the more traditional "training schools" and 
"detention centers," run by state and local juvenile 
authorities, respectively, these agencies also purchase 
care from the same group home, therapeutic foster care, 
and residential providers as do child welfare agencies. 

Children Served by the Public Sector 

Children needing services are identified under the 
auspices of five distinct types of service sectors: 
schools, juvenile justice, child welfare, general health, 
and mental health agencies. These agencies are mostly 
publicly supported, each with different mandates to 
serve various groups and to provide somewhat varied 



levels of services. Many of these agencies arose 
historically for another purpose, only to recognize later 
that mental disorders cause, contribute to, or are effects 
of the problem being addressed. In the past, these 
sectors operated somewhat autonomously, with little 
ongoing interaction. Catalyzed by the NMHA's 
Invisible Children's Project (NMHA, 1987, 1993), the 
combined impetus of Federal policies and managed 
care more recently has begun to forge their integration. 

Two recent review articles examined the 
chai"acteristics of children served in public systems. 
Based on an appraisal of six prior studies, it was 
concluded that, in addition to emotional and behavioral 
functioning, these young people have problems in life 
domains such as intellectual and educational 
performance and social and adaptive behavior 
(Friedman et al., 1996b). Frequently, such children and 
their families have contact not only with the mental 
health system, but also with special education, child 
welfare, and juvenile justice (Landrum et al., 1995; 
Duchnowski et al., 1998; Greenbaumetal., 1998; Quinn 
& Epstein, 1998). 

It is estimated that in a 1-year period more than 
700,000 children nationwide are in out-of-home 
placements, mostly under the supervision of either the 
child welfare or to some extent the juvenile justice 
system (Ghsson, 1996). Also, during the 1996-1997 
school year more than 400,000 emotionally disturbed 
children and youths between the ages of 6 and 21 were 
served in the pubhc schools nationwide (U.S. 
Department of Education, 1997). This is just under 
1 percent of the school enrollment for ages 6 to 17, and 
8.5 percent of all children with disabilities receiving 
any kind of special education service (Oswald & 
Coutinho, 1995; U.S. Department of Education, 1997). 
These figures and percentages have remained relatively 
constant since national data were first collected about 
20 years ago, although there are great variations 
between states. For example, in 1992-1993, 0.4 percent 
of school-enrolled children in Mississippi were 
identified as having a serious emotional disturbance 
compared with 2.08 percent in Connecticut (Coker et 
al., 1998). 



184 



Children and Mental Health 



In addition to children with a serious emotional 
disturbance served by the special education system, 
children served by child welfare and juvenile justice 
systems also have need for mental health services 
(Friedman & Kutash, 1986; Cohen et al., 1990; 
Greenbaumet al., 1991, 1998; Otto et al, 1992; Glisson, 
1996; Claussen et al., 1998), because they are much 
more likely to have emotional and behavioral disorders 
than is the general population (Duchnowski et al., 
1998; Quinn & Epstein, 1998). Thus, the emphasis on 
interagency community-based systems of care is 
warranted and essential (see hitegrated System Model). 

Managed Care in the Public Sector 

Since 1992, managed care has begun to penetrate the 
public sector (Essock & Goldman, 1995). The prime 
impetus for this has been an attempt to control the costs 
of Medicaid, in both the general health and mental 
health arenas. Since Medicaid appears, on the surface, 
to be similar to a private health insurance plan, 
administrators of state Medicaid programs have 
recently implemented managed care approaches and 
structures to reduce health care costs. However, 
Medicaid populations tend to have a higher prevalence 
of children with serious emotional disturbance than that 
seen in privately insured populations. Those children 
generally need longer-term care (Friedman et al., 
1996b; Broskowski & Harshbarger, 1998). Managed 
care strategies, which developed in the private sector, 
are geared toward a relatively low utilization of mental 
health services by a population whose mental health 
needs tend to be short term and acute in nature. As a 
result, the kinds of cost-cutting measures used by 
managed care organizations, such as reduction of 
hospital days and encouragement of short-term 
outpatient therapies, have not worked as well in the 
public sector with seriously emotionally disturbed 
children as they have in the private sector (Stroul et al., 
1998). 

Advocates express concern that the restrictions of 
public managed care on mental health services shift 
costs of diagnosis and treatment to other agencies, a 
process known as cost-shifting. Under public managed 
care, hospitalization for mental disorders is being 



substantially cut, with youths being discharged from 
the hospital before adequate personal and/or 
community safety plans can be instituted. Child welfare 
and juvenile justice agencies have been compelled to 
create and pay for services to support those children 
who are no longer kept in hospitals. Thus, while 
Medicaid's mental health costs may be decreasing in 
such cases, there may be a substantial cost increase to 
the other agencies involved, resulting in little if any 
overall cost saving (Stroul et al., 1998). 

Similarly, management of only the Medicaid 
portion of a complex funding system that includes 
Medicaid, mental health, special education, child 
welfare, and juvenile justice funds not only creates the 
cost-shifting described above, but also underestimates 
the need to manage the funds spent by all agencies. 
Demonstration programs of managed care strategies for 
children and adolescents with severe emotional 
disturbances have included the creation of an 
interagency funding pool, shared by all affected 
agencies, to meet the full range of needs of this 
population. Under the demonstration program, the 
funds in such a pool are capitated'^ to ensure that the 
most appropriate services are purchased, regardless of 
which agency's mandate they come under. Li this way, 
long-term, complex care can be offered in an efficient 
way that reduces costs for all of the involved child and 
youth agencies. 

An excellent example of an approach in a managed 
care setting is "Wraparound Milwaukee," one of the 
Center for Mental Health Services' Comprehensive 
Community Mental Health Services for Children and 
Their Families Programs (Stroul et al., 1998; Goldman 
& Faw, 1998). Wraparound Milwaukee, a coordinated 
system of community-based care and resources for 
families of children with severe emotional, behavioral, 
and mental health problems, is operated by the Children 
and Adolescent Services Branch of the Milwaukee 
County Mental Health Division. The features of this 
care management model are a provider network that 
furnishes an array of mental health and child welfare 
services; an individualized plan of care; a care 

'* Capitation: a fixed sum per individual per month. 



185 



Mental Health: A Report of the Surgeon General 



coordinator management system to ensure that services 
are coordinated, monitored, and evaluated; a Mobile 
Urgent Treatment Team to provide crisis intervention 
services; a managed care approach including 
preauthonzation of services and service monitoring; 
and a reinvestment strategy in which dollars saved from 
decreased use of inpatient or residential care are 
invested in increased service capacity. 

Since its inception in 1994, one of the goals of the 
program has been to blend funding streams. 
Wraparound Milwaukee operates as a behavioral health 
care "carve-out"'^ that blends funds from a monthly 
capitation rate from Medicaid, a case rate from county 
child welfare and juvenile justice funds, and a Center 
for Mental Health Services child mental health services 
grant. The Wraparound Milwaukee capitated rate of 
approximately $4,300 covers all mental health and 
substance abuse services, including inpatient 
hospitalization. Additional funds from child welfare 
and/or juvenile justice are used for children with 
serious emotional disturbances in the child welfare and 
juvenile justice systems in Milwaukee County to cover 
residential treatment, foster care, group home and 
shelter care costs, and nontraditional mental health 
community services (e.g., mentors, job coaches, after- 
school programs). Wraparound Milwaukee is at "full 
risk" for all services costs, meaning it is responsible for 
charges in excess of the capitated rate. The average 
monthly costs, including administrative costs, are 
$3,400 per child. Medicaid-eligible children constituted 
80 percent of the population served by the program in 
1998. 

Culturally Appropriate Social Support 
Services 

One of the fundamental requirements of culturally 
appropriate services is for mental health providers to 
identify and then to work in concert with natural 
support systems within the diverse communities they 
serve (Greenbaum, 1998). (Background information on 
cultural diversity and culturally competent services is 



" Carve-out: separation of funding for mental health services and 
their management from those of general health. 



provided in Chapter 2.) If they are culturally 
appropriate, services can transcend mental health's 
focus on the "identified client" to embrace the 
community, cultural, and family context of a client 
(Szapocznik&Kurtines, 1993; Hernandez etal., 1998). 
According to Greenbaum (1998), considering a client's 
context is important because people who live close to 
each other frequently have developed ways of coping 
with similar personal problems. Becoming aware of 
these natural systems and adapting formal services to 
be congruent with them are ways to make services more 
accessible and useful to diverse populations. 

Community- and neighborhood-based social net- 
works act as important resources for easing emotional 
stress and for facilitating the process of seeking 
professional help (Saunders, 1 996). Often natural social 
supports ameliorate emotional distress and have been 
found to reduce the need for formal mental health 
treatment (Linn & McGranahan, 1980; Birkel & 
Reppucci, 1983; Cohen & Wills, 1985). According to 
Saunders (1996), obtaining social support is not a 
single event but rather an ongoing process, hi general, 
people use their neighborhood and familial supports 
many times before they decide they have a problem and 
determine what type of help they will seek (Rew et al., 
1997). A key to the success of mental health programs 
is how well they use and are connected with 
estabhshed, accepted, credible community supports. 
The more this is the case, the less likely families view 
such help as threatening and as carrying stigma; this is 
particularly true for families who are members of racial 
andethnic minority groups (Bentelspac her etal., 1994). 

Minority parents are more likely than nonminority 
parents to seek input regarding their children from 
family and community contacts (Briones et al., 1990; 
Hoberman, 1992). In a study by McMiller and Weisz 
(1996), two-thirds of the parents of minority children 
did not seek help from professionals and agencies as 
their first choice. For example, in Hispanic/Latino 
families, important decisions related to health and 
mental health are often made by the entire family 
network rather than by individuals (Council of 
Scientific Affairs, 1991). According to Ruiz (1993), 
health care settings that are not modified to work with 



186 



Children and Mental Health 



Hispanic/Latino family networks find that their clients 
do not comply with medical advice; as a result, their 
health status can be compromised. 

In sum, mental health programs attempting to serve 
diverse populations must incorporate an understanding 
of culture, traditions, beliefs, and culture-specific 
family interactions into their design (Dasen et al., 1 988) 
and form working partnerships with communities in 
order to become successful (Kretzman & McKnight, 
1993). Ultimately, the solution offered by professionals 
and the process of problem resolution or treatment 
should be consistent with, or at least tolerable to, the 
natural supportive environments that reflect clients' 
values and help-seeking behaviors (Lee, 1996). 

Such partnerships sometimes fail, however, 
because they concentrate on neighborhood and 
community problems. According to Kretzman and 
McKnight (1993), this approach often reinforces the 
negative stereotypes of violent, drug- and gang-ridden, 
and poverty-stricken communities. A more effective 
alternative approach to working with communities is to 
focus on community strengths (Kretzman & McKnight, 
1993). This approach works best when community 
residents themselves are interested in participating in 
the partnership. Mental health providers who approach 
minority communities in a paternalistic manner fail to 
engage residents and fail to recognize whether the 
community wants their assistance (Gutierrez-Mayka & 
Contreras-Neira, 1998). Service providers who attend 
to the wishes of community residents are more likely to 
be respectful in their delivery of services, a respect that 
is a prerequisite to cultural responsiveness and 
competence in service planning and delivery to diverse 
communities (Gutierrez-Mayka & Contreras-Neira, 
1998). 

Support and Assistance for Families 

Any parent or guardian of a child with an emotional or 
behavioral disorder can testify to the challenging, 
sometimes overwhelming, task of caring for and raising 
such a child. In the past, support from public agencies 
has been inadequate and disjointed. Compounding the 
problem was the view that parents were partly, if not 
completely, to blame for their child's condition 



(Friesen & Stephens, 1998). In 1982, a particularly 
incisive description of the problems faced by families 
raising children with emotional or behavioral disorders 
was published. It concluded that parents received little 
assistance in finding services for their children and 
were either ignored or coerced by public agencies; 
respite and support services to relieve the stress on 
parents were unavailable; parents with children needing 
residential care were compelled to give up custody to 
get them placed; and few advocacy efforts were aimed 
at relieving their problems (Knitzer, 1982). 

Over the past two decades, however, recognition 
and response to the plight of families have become 
increasingly widespread. The role of families has been 
redefined as that of a partner in care. Furthermore, 
there was growing awareness of the difficulties families 
faced because services are provided by so many 
different public sources. In addition to problems with 
coordination, parents and caregivers encountered 
conflicting requirements, different atmospheres and 
expectations, and contradictory messages from system 
to system, office to office, and provider to provider 
(Knitzer, 1982). Although some agencies began to 
provide families with training, information, education, 
and financial assistance, there was often a gap between 
what families needed and what agencies provided. 
Also, service agencies themselves began to recognize 
that putting children into institutions may not have 
served the child, the family, or the state and that 
keeping a child with his or her family could reduce the 
ever-growing costs of institutionalization (Stroul, 
1993a, 1993b). Emerging awareness of these foregoing 
problems galvanized advocacy for a better way to care 
for children with emotional and behavioral disorders. 
Reforms were instituted in many Federal programs, as 
discussed later in this section. 

According to Knitzer and colleagues (1993), family 
participation promotes four changes in the way children 
are served: increased focus on families; provision of 
services in natural settings; greater cultural sensitivity; 
and a community-based system of care. Research is 
accumulating that family participation improves the 
process of delivering services and their outcomes. For 
example, Koren and coworkers (1997) found that, for 



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Mental Health: A Report of the Surgeon General 



children with serious mental health problems, the more 
the family participates in planning services, the better 
family members feel their children's needs are being 
met; participation in service planning also helps service 
coordination. Curtis and Singh (1996) and Thompson 
and colleagues (1997) also found that family 
involvement in services was a determinant of the level 
of parental empowerment, that is, how much control 
parents felt they had over their children's treatment. 

New Roles for Families in Systems of Care 

Over the past two decades, the Federal government 
established a series of initiatives to support families. 
Parents were given progressively greater roles as 
decisionmakers with the passage of the Education of 
the Handicapped Act in 1975 and its successor 
legislation, the Individuals with Disabilities Education 
Acts of 1991 and 1997. For simplicity, these pieces of 
legislation are collectively referred to hereinafter as the 
IDEA Act. This act requires parent involvement in 
decisions about educating children with disabilities. It 
guarantees that all children with disabilities receive 
free and appropriate public education. It also provides 
funding assistance to states for implementation. 

A novel approach taken by some community-level 
systems of care to encouraging involvement of families 
is to train and hire family members into a wide range of 
well-paying, career-ladder jobs as outreach workers, 
service coordinators (sometimes called case managers), 
and direct support services providers. These positions 
are critical to achieving major program goals because 
they make it possible for children and families to 
remain together and to participate in the more clinical 
components of tl|eir service plan. Family members are 
also employed as supervisors of services, involved in 
hiring staff, providing them with orientation and on- 
the-job training (e.g., of case managers), overseeing 
their work, and evaluating their performance. They also 
participate in research. 

Beginning in 1989, the Child and Adolescent 
Service System Program, a component of the Center for 
Mental Health Services, began providing some support 
for statewide family organizations through a series of 
funding and technical assistance mechanisms (Koroloff 



et al., 1991; Briggs et al., 1994; also see Integrated 
System Model). Such organizations were funded to 
develop statewide networks of information and support 
for families, to coordinate with other organizations that 
shared common goals, and to promote needed changes. 
Currently, Federal funding for 22 statewide family 
organizations is provided through the Child and Family 
Branch, Center for Mental Health Services, Substance 
Abuse and Mental Health Services Administration. 
Support and technical assistance to community-level 
family organizations are also provided by the 
Federation of Families for Children's Mental Health, 
the National Alliance for the Mentally HI, and other 
family-run consumer organizations. 

Family Support 

Family support is defined here as the assistance given 
to families to cope with the extra stresses that 
accompany caring for a child with emotional 
disabilities. In addition to the stress of raising a child 
with an emotional disability, families often face other 
difficulties such as poverty, joblessness, substance 
abuse, and victimization. Family support often helps 
keep families together by assisting them with the 
practicalities of living and by attending to the needs of 
all family members (Will, 1998). The main goal of 
family support services is to strengthen adults in their 
roles as parents, nurturers, and providers (Weissbourd 
& Kagan, 1989). Too often, family support services are 
not available within local communities. 

Natural support systems are often diminished for 
families of children with serious emotional, behavioral, 
or physical disorders or handicaps because of the 
stigma of, or embarrassment about, their child's 
problems, or because caregivers have insufficient 
energy to reach out to others. Not surprisingly, most 
parents report that limited social support decreases 
their quality of life (Crowley & Kazdin, 1998) and that 
they feel less competent, more depressed, worried, and 
tired and have more problems with spouses and other 
family relationships than other parents (Farmer et al., 
1997), although a few families do feel enriched by 
caring for these children (Yatchmenoff et al., 1998). 



188 



Children and Mental Health 



In a national survey of parents of children with an 
emotional or behavioral disorder, 72 percent of 
respondents indicated that emotional support 
(irrespective of its form) was the most helpful aspect of 
family support services (Friesen, 1990). Benefits 
included increased access to information, improved 
problem-solving skills, and more positive views about 
parenting and their children's behavior (Friesen & 
Koroloff, 1990). 

Family support services occur in several forms: 
assistance with daily tasks and psychosocial support 
and counseling; informal or professional provision of 
services; and practical support such as housing 
assistance, food stamps, income support, or respite care 
(i.e., temporary relief for family members caring for 
individuals with disabilities). 

Efforts to stop blaming parents for children's 
problems have resulted in parents becoming viewed 
less as patients than as partners, actively involved in 
every phase of the treatment process (e.g., home-based 
care, case management) and as a resource for their 
children, as discussed above. For the self-help and 
professionally led family support services described 
subsequently, parents may function either as partners or 
as providers. As "partners," parents act as a resource, 
active contributor, or decisionmaker; as "providers," 
they are viewed as contributing to the welfare and 
growth of other members of the family. 

Results of research on the effectiveness of family 
services are only beginning to appear, in the form of 
some controlled studies and evaluations of support 
services for families of children with emotional and 
behavioral disorders (although there is a larger 
literature on families whose children have other types 
of disability and illness). Although this database on 
family support programs is still limited, many positive 
effects have been reported. The following paragraphs 
cover family support groups as well as concrete 
services. For the latter, only two types of interventions, 
respite care and the family associate, are included. 
Family therapy is covered in this chapter under 
Outpatient Treatment. Furthermore, several forms of 
parent training were found to be effective for individual 



diagnoses, such as conduct disorder (see section on 
Selected Mental Disorders in Children). 

Family Support Groups 

The primary focus of family support groups is to 
provide information and emotional support to members 
who share a common problem or concern (e.g., 
disability, substance abuse, bereavement). Support 
groups for families of children with emotional or 
behavioral disorders are expanding. Although there is 
a wide variation in membership, format, and duration 
of these groups, most share some characteristics. 
Usually, from 4 to 20 parents meet regularly to discuss 
the problems and issues associated with parenting a 
child with emotional and behavioral disorders and to 
provide mutual encouragement and suggestions for 
dealing with problematic situations. Support services 
may be informal, organized, and parent led and are 
often associated with organizations such as the 
National Mental Health Association, Children and 
Adults with Attention Deficit Disorders, the National 
Alliance for the Mentally Dl, or the Federation of 
Families for Children's Mental Health. Mental health 
professionals may also participate in support groups 
(Koroloff & Friesen, 1991). 

It was found that support groups for parents of 
children hospitalized with mental illness make parents 
feel more positive about themselves and increase their 
understanding of and communication with their 
children (Dreier & Lewis, 1991). Participation in a six- 
session education and support group for parents of 
adolescents with schizophrenia led to increased 
relaxation and concentration, less worry, changed 
attitudes toward discipline, and greater ease in 
discussing feelings. The support from parents in similar 
situations was highly valued (Sheridan & Moore, 
1991). 

Another approach to support for parents of children 
receiving mental health services is education: 
knowledge of the services; skills needed to interact 
with the system; and the caregivers' confidence in their 
ability to collaborate with service providers (self- 
efficacy). A training curriculum for parents was tested 
in a randomized controlled trial involving more than 



189 



Mental Health: A Report of the Surgeon General 



200 parents who either did or did not receive the 
training curriculum. Three-month and 1-year followup 
results demonstrated significant improvement in 
parents' knowledge and self-efficacy with the training 
curriculum, whereas there was no effect on the mental 
health status of their children, service use, or caregiver 
involvement in treatment (Heflinger & Bickman, 1996; 
Bickman et al., 1998). 

Practical Support ! 

Respite care is a type of concrete support that provides 
temporary relief to family caregivers. An investigation 
of the benefit of respite care is under way in New York 
in families with children at risk of hospital placement. 
When respite care was available, families preferred in- 
home to out-of-home care. The younger the children, 
the greater the child's functional impairment, and the 
fewer the social supports (Boothroyd et al., 1998), the 
more respite care was used. Outcomes have not yet 
been reported. 

Another form of concrete support is exemplified by 
the Family Associate Intervention, which was 
developed in Oregon. It appears to be an inexpensive 
way to assist children in actually obtaining care after 
they have been identified as needing care. The goal is 
to use paraprofessionals (known as family associates), 
rather than professionals, to facilitate entry into an 
often intimidating service system. In a controlled study, 
family associates were found to be effective in helping 
families initiate mental health service use. Families 
receiving this support service were more likely to make 
and keep a first appointment at the mental health clinic. 
The effectiveness of the intervention was moderate but 
sufficient to encourage further development of such a 
low-cost intervention (Koroloff et al., 1996b; EUiot et 
al, 1998). 

Integrated System Model 

Within the public mental health system, the 1980s and 
1990s have seen an increased emphasis on developing 
interagency community-based systems of care (Stroul 
& Friedman, 1986). This focus is driven by awareness 
that a large number of children are served in systems 
other than mental health, as well as by children's 



complex and interrelated needs, as indicated earlier 
(Friedman et al., 1996a, 1996b; Quinn & Epstein, 
1998). In 1984, the Child and Adolescent Service 
System Program (CASSP) was launched to respond to 
the fragmentation of public services (Stroul & 
Friedman, 1986). It was funded by the services 
component of the National Institute of Mental Health, 
which later became the Center for Mental Health 
Services under the Alcohol and Drug Abuse and 
Mental Health Administration Reorganization Act of 
1992 (Public Law 102-321). 

CASSP recognized the need for public sector 
programs to become more integrated in their attempts 
to meet more fully and efficiently the needs of children 
and adolescents with a serious emotional disturbance 
and their families. This Federal program pioneered the 
concept of a "system of care" for this population, as 
delineated by Stroul and Friedman (1986, 1996). A 
system of care, described further below, is a 
comprehensive approach to coordinating and delivering 
a far-reaching array of services from multiple agencies. 
All 50 states and numerous communities have received 
CASSP grants to improve the organization of their 
response to the mental health needs of the most 
severely affected children and adolescents. Although 
CASSP principles have become a standard for program 
design, many communities do not offer comprehensive 
services according to the CASSP model. 

CASSP provided the conceptual framework for the 
Robert Wood Johnson Foundation's Mental Health 
Services Program for Youth and the Annie E. Casey 
Foundation's Urban Mental Health Initiative. These 
foundation programs were devoted to the development 
of local interagency models (Cole, 1990). They were 
followed in 1992 by the authorization for what was to 
become the largest Federal program for child mental 
health, the Comprehensive Community Mental Health 
Services for Children and Their Families Program (also 
known as the Children's Services Program), sponsored 
by the Center for Mental Health Services (Public Law 
102-321). 

The Children's Services Program provides grants 
to states, communities, territories, and Indian tribes and 
tribal organizations to improve and expand systems of 



190 



Children and Mental Health 



care to meet the needs of approximately 6.3 million 
children and adolescents with serious emotional 
disturbance and their families. The program now 
supports 45 sites across the country. 

Built on the principles of CASSP, the Children's 
Services Program promotes the development of service 
delivery systems through a "system of care" approach. 
The system of care approach embraced by this initiative 
is defined as a comprehensive spectrum of mental 
health and other services and supports organized into a 
coordinated network to meet the diverse and changing 
needs of children and adolescents with serious 
emotional disturbance and their families (Stroul & 
Friedman, 1996). The system of care model is based on 
three main elements: (1) the mental health service 
system must be driven by the needs and the preferences 
of the child and family; (2) the locus and management 
of services must be within a multiagency collaborative 
environment, grounded in a strong community base; 
and (3) the services offered, the agencies participating, 
and the programs generated must be responsive to 
children's different cultural backgrounds. The 
Children's Services Program requires a national cross- 
site evaluation, which has been continuously 
implemented since the spring of 1994. Preliminary 
evidence from the uncontrolled evaluation indicates 
some improvements in outcomes, such as fewer law 
enforcement contacts and better school grades, living 
arrangements, and mental health status. As part of the 
evaluation, comparisons are being made between 
system of care sites and comparable communities 
without systems of care (Holden et al., 1999). 

Effectiveness of Systems of Care 

The previous sections have highlighted the trans- 
formations that have taken place since the early 1980s 
to create comprehensive, interagency, community- 
based systems of care. This section reviews the 
findings of research into the effectiveness of such 
systems of care as compared with more traditional 
systems. 

Several studies on the effectiveness of systems of 
care have been conducted in recent years (Stroul, 
1993a, 1993b; Bruns et al., 1995; Rosenblatt, 1998). 



Although findings are encouraging, their effectiveness 
has not yet been demonstrated conclusively, largely 
because evaluation studies have not had a control 
group. Most evaluations indicate that systems of care 
reduce rates of reinstitutionalization after discharge 
from residential settings, reduce out-of-state place- 
ments of children, and improve other individual 
outcomes such as number of behavior problems and 
satisfaction with services. After reviewing findings 
from the demonstration project of the Robert Wood 
Johnson Foundation, their own work in Vermont, 
research in California and Alaska, and early findings 
from the Fort Bragg evaluation, Bruns, Burchard, and 
Yoe (1995) conclude that "initial findings are encourag- 
ing, especially with the history of disappointing results 
of outcome studies for child and adolescent services" 
(p. 325). Details are available in the individual studies 
(Attkisson et al., 1997; Illbacket al., 1998; Santarcan- 
gelo et al, 1998). 

Reviews (Stroul, 1993a, 1993b; Rosenblatt, 1998) of 
uncontrolled studies of community-based systems of 
care showed that young people with serious emotional 
disturbances who were served under community-based 
systems of care consistently showed improvement 
across a range of outcomes. However, most of these 
studies used a so-called pre-post evaluation design that 
does not answer the question of whether the changes 
occurring over time (pre to post) are a consequence of 
the intervention or of the passage of time itself. Lideed, 
when comparison groups are studied, such as in the 
Fort Bragg demonstration project, results tend to be 
less favorable (see below). 

The Fort Bragg Study 

The Fort Bragg study, conducted by Bickman and his 
colleagues (Bickman et al., 1995; Bickman, 1996a; 
Hamner et al., 1997), merits detailed discussion 
because of the basic issues it raises and the controversy 
it engendered. The Fort Bragg study is an evaluation of 
a large-scale system change project initiated by the 
State of North Carolina and the Department of Defense 
in the early 1990s; it was designed to determine what 
systemic, clinical, and functional outcomes could be 



191 



Mental Health: A Report of the Surgeon General 



achieved if a wide range of individualized and family- 
centered services were provided without any barriers to 
their availability. The project involved replacing the 
traditional CHAMPUS benefit for children who were 
military dependents in the Fort Bragg area with a 
continuum of care that included a broad range of 
services, a single point of entry, comprehensive 
assessments, and no copayment or benefit limit. The 
provider agency at Fort Bragg was reimbursed for 
costs. The impact of this change on children was 
assessed by comparing outcomes at Fort Bragg with 
those at two other military installations in the Southeast 
where the traditional CHAMPUS benefit package 
remained in effect. The comparison sites restricted 
services to outpatient treatment, placement in a 
residential treatment center, or treatment in an inpatient 
hospital setting; regular copayment and benefit limits 
were in effect at the comparison sites. 

Over a 3 -year period, the e valuators collected 
service use, cost, satisfaction, clinical, and functional 
data for 984 young people served either at Fort Bragg 
(574) or the comparison sites (410). Overall, there were 
a number of favorable findings for the demonstration 
site at Fort Bragg: access for children was increased; 
children referred for services were indeed in need of 
help; parents and adolescents were more satisfied with 
the services they received than were parents and 
adolescents at the comparison sites; children received 
services sooner; care was provided in less restrictive 
environments; there was heavy use of intermediate- 
level services; fewer clients received only one session 
of outpatient treatment; overall, children stayed in 
treatment longer (although the length of stay in 
hospitals and residential treatment centers was shorter); 
and there were fewer disruptions in services (Bickman, 
1996a). Thus, the major findings were that the 
expanded continuum of care resulted in greater access, 
higher satisfaction with services by patients, and less 
use of inpatient hospitalization and residential 
treatment. Bickman also concluded, however, that 
despite the fact that the intervention was well 
implemented at Fort Bragg, there were no differences 
between sites in clinical outcomes (emotional- 



behavioral functioning), and the cost was considerably 
greater at Fort Bragg. 

The interpretation of the results by the project's 
principal investigator has generated much discussion 
and controversy in the children's mental health field, 
both in support of and questioning the study's 
conclusions (Friedman & Bums, 1996; Behar, 1997; 
Feldman, 1997; Hoagwood, 1997; Lourie, 1997; Pires, 
1997; Saxe & Cross, 1997; Sechrest & Walsh, 1997; 
Weisz et al., 1997). Most of the controversy surrounds 
study interpretation, implementation, methodology, and 
the interpretation of the cost data (Behar, 1997; 
Feldman, 1997; Heflinger & Northrup, 1997; 
Langmeyer, 1 997 ) . Furthermore, it has been pointed out 
that Fort Bragg was not a multiagency community- 
based system of care (Friedman & Bums, 1996), a 
point that has been acknowledged by the principal 
investigator of the study (Bickman, 1996b). Overall, 
despite the controversy surrounding it, the Fort Bragg 
evaluation has challenged the notion that changes at the 
system level have consequences at the practice level 
and, ultimately, improve outcomes for children and 
families. The results have stimulated an increased focus 
on practice-level issues. 

The Stark County Study 

The shift in focus to the practice level is being re- 
inforced by results from another study by Bickman and 
colleagues (1997, 1999) of children with emotional 
disturbances who were served in Stark County, Ohio. 
In this study, participating children were served within 
the public mental health system by a multiagency 
system of care; this was in contrast to the Fort Bragg 
sample of military dependents seen in a mental health- 
funded and -operated continuum of care. Children and 
families who consented to participate in the study were 
randomly assigned to one of two groups. The first 
group was immediately eligible to receive services 
within the existing community-based system of care in 
Stark County. Families in the second group were 
required to seek services on their own rather than to 
receive them within the system of care. The major 
differences in services provided were that significantly 



192 



Children and Mental Health 



more children and families in the system of care group 
received case management and home visits than those 
in the comparison group. Findings indicate no 
differences in clinical or functional status 12 months 
after intake. These results are similar to those of the 
Fort Bragg study and suggest that attention should be 
paid to the effectiveness of services delivered within 
systems of care rather than only to the organization of 
these systems. 

Summary: Effectiveness of Systems of Care 

Collectively, the results of the evaluations of systems 
of care suggest that they are effective in achieving 
important system improvements, such as reducing use 
of residential placements, and out-of-state placements, 
and in achieving improvements in functional behavior. 
There also are indications that parents are more 
satisfied in systems of care than in more traditional 
service delivery systems. The effect of systems of care 
on cost is not yet clear, however. Nor has it yet been 
demonstrated that services delivered within a system of 
care will result in better clinical outcomes than services 
delivered within more traditional systems. There is 
clearly a need for more attention to be paid to the 
relationship between changes at the system level and 
changes at the practice level. 

Conclusions 

1 . Childhood is characterized by periods of transition 
and reorganization, making it critical to assess the 
mental health of children and adolescents in the 
context of familial, social, and cultural 
expectations about age-appropriate thoughts, 
emotions, and behavior. 

2. The range of what is considered "normal" is wide; 
still, children and adolescents can and do develop 
mental disorders that are more severe than the "ups 
and downs" in the usual course of development. 

3. Approximately one in five children and adoles- 
cents experiences the signs and symptoms of a 
DSM-FV disorder during the course of a year, but 
only about 5 percent of all children experience 
what professionals term "extreme functional im- 
pairment." 



4. Mental disorders and mental health problems 
appear in families of all social classes and of all 
backgrounds. No one is immune. Yet there are 
children who are at greatest risk by virtue of a 
broad array of factors. These include physical 
problems; intellectual disabilities (retardation); low 
birth weight; family history of mental and addictive 
disorders; multigenerational poverty; and caregiver 
separation or abuse and neglect. 

5. Preventive interventions have been shown to be 
effective in reducing the impact of risk factors for 
mental disorders and improving social and 
emotional development by providing, for example, 
educational programs for young children, parent- 
education programs, and nurse home visits. 

6. A range of efficacious psychosocial and 
pharmacologic treatments exists for many mental 
disorders in children, including attention- 
deficit/hyperactivity disorder, depression, and the 
disruptive disorders. 

7. Research is under way to demonstrate the 
effectiveness of most treatments for children in 
actual practice settings (as opposed to evidence of 
"efficacy" in controlled research settings), and 
significant barriers exist to receipt of treatment. 

8 . Primary care and the schools are maj or settings for 
the potential recognition of mental disorders in 
children and adolescents, yet trained staff are 
limited, as are options for referral to specialty care. 

9. The multiple problems associated with "serious 
emotional disturbance" in children and adolescents 
are best addressed with a "systems" approach in 
which multiple service sectors work in an 
organized, collaborative way. Research on the 
effectiveness of systems of care shows positive 
results for system outcomes and functional 
outcomes for children; however, the relationship 
between changes at the system level and clinical 
outcomes is still unclear. 

10. Families have become essential partners in the 
delivery of mental health services for children and 
adolescents. 

11. Cultural differences exacerbate the general 
problems of access to appropriate mental health 



193 



Mental Health: A Report of the Surgeon General 



services. Culturally appropriate services have been 
designed but are not widely available. 

References 

Abikoff, H. (1985). Efficacy of cognitive training 

interventions in hyperactive children: A critical review. 

Clinical Psychology Review, 5, 479-512. 
Abramowitz, A. J., Eckstrand, D., O'Leary, S. G., & Dulcan, 

M. K. (1992). ADHD children's responses to stimulant 

medication and two intensities of a behavioral 

intervention. Behavior Modification, 16, 193-203. 
Abramson, L. Y., Seligman, M. E., & Teasdale, J. D. (1978). 

Learned helplessness in humans: Critique and 

reformulation. Journal of Abnormal Psychology, 87, 

49-74. 
Achenbach, T. M., & Edelbrock, C. 3.(19^). Manual of child 

behavior checklist and revised child behavior profile. 

Burlington, VT: University of Vermont, Department of 

Psychiatry. 
Akiskal, H. S. (1983). Dysthymic disorder: Psychopathology 

of proposed chronic depressive subtypes. American 

Journal of Psychiatry, 140, 1 1-20. 
Alexander, J. P., & Parsons, B. V. (1973). Short-term 

behavioral intervention with delinquent families: Impact 

on family process and recidivism. Journal of Abnormal 

Psychology, 81, 219-225. 
Allgood-Merten, B., Lewinsohn, P. A., & Hops, H. (1990). 

Sex differences and adolescent depression. Journal of 

Abnormal Psychology, 99, 55-63. 
American Academy of Child and Adolescent Psychiatry. 

(1991). Practice parameters for the assessment and 

treatment of attention deficit/hyperactivity disorders. 

Journal of the American Academy of Child and 

Adolescent Psychiatry, 30, 1-3. 
American Academy of Child and Adolescent Psychiatry. 

(1998). Practice parameters for the assessment and 

treatment of children and adolescents with depressive 

disorders. AACAP. Journal of the American Academy of 

Child and Adolescent Psychiatry, 37, 63S-83S. 
American Academy of Pediatrics Committee on Children with 

Disabihties and Committee on Drugs. (1996). Medication 

for children with attentional disorders. Pediatrics, 98, 

301-304. 
American PsychiaUic Association. (1980). Diagnostic and 

statistical manual of mental disorders (3rd ed.). 

Washington, DC: Author. 
American Psychiatric Association. (1987). Diagnostic and 

statistical manual of mental disorders (3rd ed.-rev.). 

Washington, DC: Author 
American Psychiatric Association. (1994). Diagnostic and 

statistical manual of mental disorders (4th ed.). 

Washington, DC: Author 



Anderson, J. C, & McGee, R. (1994). Comorbidity of 
depression in children and adolescents. In W. M. 
Reynolds & H. F. Johnson (Eds.), Handbook of 
depression in children and adolescents (pp. 581-601). 
New York: Plenum. 

Anderson, J. C, Wilhams, S. C, McGee, R., & Silva, P. A. 
(1987). DSM-m disorders in preadolescent children: 
Prevalence in a large sample from the general population. 
Archives of General Psychiatry, 44, 69-76. 

Angold, A., & CosteUo, E. J. (1993). Depressive comorbidity 
in children and adolescents: Empirical, theoretical, and 
methodological issues. American Journal of Psychiatry, 
150, 1779-1791. 

Angold, A., & Costello, E. J. (1998). Stimulant treatment for 
children: A community perspective. Manuscript submitted 
for publication. 

Apsler, R., & Hodas, M. (1976). Evaluating hothnes with 
simulated calls. Crisis Intervention, 6, 14-21. 

Armbruster, P., & Fallon, T. (1994). CUnical, 
sociodemographic, and systems risk factors for attrition in 
a children's mental health clinic. American Journal of 
Orthopsychiatry, 64, 577-585. 

Aronson, M., Hagberg, B., & Gillberg, C. (1997). Attention 
deficits and autistic spectrum problems in children 
exposed to alcohol during gestation: A follow-up study. 
Developmental Medicine and Child Neurology, 39, 
583-587. 

Asamow, J. R., Tompson, M., Hamilton, E. B., Goldstein, M. 
J., & Guthrie, D. (1994). Family-expressed emotion, 
childhood-onset depression, and childhood-onset 
schizophrenia spectrum disorders: Is expressed emotion 
a nonspecific correlate of child psychopathology or a 
specific risk factor for depression? Journal of Abnormal 
Child Psychology, 22, 129-146. 

Attkisson, C. C, Dresser, K. L., & Rosenblatt, A. (1995). 
Service systems for youth with severe emotional 
disorders: System-of-care research in California. In L. 
Bickman & D. J. Rog (Eds.), Children 's mental health 
services: Research, policy, and evaluation (pp. 236-280). 
Thousand Oaks, CA: Sage. 

Attkisson, C. C, Rosenblatt, A., Dresser, K. L., Baize, H. R., 
Clausen, J. M., & Lind, S. L. (1997). Effectiveness of the 
California system of care model for children and youth 
with severe emotional disorder. In C. T. Nixon & C. A. 
Northrup (Eds.), Evaluating mental health services: How 
do programs for children "work" in the real world? (pp. 
146-208). Thousand Oaks, CA: Sage. 

Baenen, R. S., Stephens, M. A., & Glenwick, D. S. (1986). 
Outcome in psychoeducational day school programs: A 
review. American Journal of Orthopsychiatry, 56, 
263-270. 

Baer, R. A., & Nietzel, M. T. (1991). Cognitive and 
behavioral treatment of impulsivity in children: A meta- 
analytic review of the outcome literature. Journal of 
Clinical Child Psychology, 20, 400-412. 



194 



Children and Mental Health 



Bailey, A., Le Couteur, A., Gottesman, I., Bolton, P., 
Simonoff, E., Yuzda, E., & Rutter, M. (1995). Autism as 
a strongly genetic disorder: Evidence from a British twin 
study. Psychological Medicine, 25, 63>-ll. 

Bandura A. (1971). Psychological modeling: Conflicting 
theories. Chicago: Aldine-Atherton. 

Bandura, A. (1977). Social learning theory. Englewood CUffs, 
NJ: Prentice Hall. 

Barker,P. (1982). Residential treatment for disturbed children: 
Its place in the '80s. Canadian Journal of Psychiatry, 27, 
634-639. 

Barker, P. (1998). The future of residential treatment for 
children. In C. Schaefer & A. Swanson (Eds.), Children 
in residential care: Critical issues in treatment, (pp. 
1-16). New York: Van Nostrand Reinhold. 

Barkley, R. A. ( 1 990). Attention-deficit hyperactivity disorder: 
A handbook for diagnosis and treatment. New York: 
Guilford Press. 

Barkley, R. A. {\99%). Attention-deficit hyperactivity disorder: 
A handbook for diagnosis and treatment (2nd ed.). New 
York: Guilford Press. 

Barkley, R. A., Karlsson, J., Pollard, S., & Murphy, J. V. 
(1985). Developmental changes in the mother-child 
interactions of hyperactive boys: Effects of two dose 
levels of RitaUn. Journal of Child Psychology and 
Psychiatry and Allied Disciplines, 26, 705-715. 

Bamett, W. W. (1995). Lxjng-term effects of early childhood 
programs on cognitive and school outcomes. The Future 
of Children, 5(3), 25-50. 

Barrett, P. M., Dadds, M. R., & Rapee, R. M. (1996). Family 
treatment of childhood anxiety: A controlled trial. Journal 
of Consulting and Clinical Psychology, 64, 333-342. 

Beck, A. T. (1987). Cognitive models of depression. Journal 
of Cognitive Psychotherapy Institute Quarterly, 1, 5-37. 

Beck, A. T., Ward, C. H., Mendelson, M., Mock, J. E., & 
Erbaugh, J. K. (1961). An inventory for measuring 
6.&()res,s,\on. Archives of General Psychiatry, 4, 561-571. 

Becker, A. E., Grinspoon, S. K., Klibanski, A., & Herzog, D. 
B. (1999). Eating disorders. New England Journal of 
Medicine, 340, 1092-1098. 

Behar, L. B. (1997). The Fort Bragg evaluation: A snapshot in 
time. American Psychologist, 52, 557-559. 

Belsky, J., & Rovine, M. (1987). Temperament and 
attachment security in the strange situation: An empirical 
approachment. Child Development, 58, 787-795. 

Bentelspacher, C. E., Chitran, S., & Rahman, M. A. (1994). 
Coping and adaptation patterns among Chinese, Indian, 
and Malay families caring for a mentally ill relative. 
Families in Society: The Journal of Contemporary 
Human Services, 75, 287-297. 

Bemal, M. E., Klinnert, M. D., & Schultz, L. A. (1980). 
Outcome evaluation of behavioral parent training and 
cUent-centered parent counseling for children with 
conduct problems. Journal of Applied Behavior Analysis, 
13, 677-691. 



Bernstein, G. A., Borchardt, C, Perwein, A., Crosby, R., 
Kushner, M., & Thuras, P. (1998, October). Treattnentof 
school refusal with imipramine. Poster session presented 
at the 45th annual meeting of the American Academy of 
Child and Adolescent Psychiatry, Anaheim. CA. 

Berrento-Clement, J. R., Schweinhart, L. J., Bamett, W. S., 
Epstein, A. S., & Weikart, D. P. (1984). Changed lives: 
The effects of the Perry Preschool Program on youths 
through age 19. Ypsilanti, MI: The High/Scope Press. 

Bickman, L. (1996a). Implications of a children's mental 
health managed care demonstration project. Journal of 
Mental Health Administration, 23, 107-117. 

Bickman, L. (1996b). Reinterpreting the Fort Braggg 
evaluation findings: The message does not change. 
Journal of Mental Health Administration, 23, 137-145. 

Bickman, L., Guthrie, P. R., & Foster, E. M. (1995). 
Evaluating managed mental health care: The Fort Bragg 
experiment. New York: Plenum. 

Bickman, L., Heflinger, C. A., Northrup, D., Sonnichsen, S., 
& Schilhng, S. (1998). Long term outcomes to family 
caregiver empowerment. Journal of Child and Family 
Studies, 7, 269-282. 

Bickman, L., Noser, K., & Summerfelt, W. T. (1999). Long- 
term effects of a system of care on children and 
adolescents. Journal of Behavioral Health Services & 
Research, 26, 185-202. 

Bickman, L., Summerfelt, W. T., & Noser, K. (1997). 
Comparative outcomes of emotionally disturbed children 
and adolescents in a system of services and usual care. 
Psychiatric Services, 48, 1543-1548. 

Bidell, T. R., & Fischer, K. W. (1992). Beyond the stage 
debate: Action, structure, and variabiUty in Piagetian 
theory and research. In R. Sternberg & C. Berg (Eds.), 
Intellectual development (pp. 100-141). New York: 
Cambridge University Press. 

Biederman, J., Faraone, S., Mick, E., & Lelon, E. (1995). 
Psychiatric comorbidity among referred juveniles with 
major depression: Fact or artifact? Journal of the 
American Academy of Child and Adolescent Psychiatry, 
34, 579-590. 

Biederman, J., Rosenbaum, J., Bolduc-Murphy, E., Faraone, 
S., Chaloff, J., Hirshfeld, D., & Kagan, J. (1993). A three- 
year follow-up of children with and without behavioral 
inhibition. Journal of the American Academy of Child and 
Adolescent Psychiatry, 32, 814-821. 

Birckmayer, J., & Hemenway, D. (1999). Minimum-age 
drinking laws and youth suicide, 1970-1990. American 
Journal of Public Health, 89, 1365-1368. 

Bird, H..R., Canino, G., Rubio-Stipec, M., Gould, M. S., 
Ribera, J., Sesman. M., Woodbury, M., Huertas-Goldman, 
S., Pagan, A., Sanchez-Lacay, A., & Moscoso, M. (1988). 
Estimates of the prevalence of childhood maladjustment 
in a community survey in Puerto Rico. The use of 
combined measures. Archives of General Psychiatry, 45, 
1120-1126. 



195 



Mental Health: A Report of the Surgeon General 



Birkel, R. C, & Reppucci, N. D. (1983). Social networks, 
information-seeking, and the utilization of services. 
American Journal of Community Psychology, 11, 
185-205. 

Birmaher, B., Ryan, N. D., Williamson, D. E., Brent, D. A., & 
Kaufman, J. (1996a). Childhood and adolescent 
depression: A review of the past 10 years. Part II. Journal 
of the American Academy of Child and Adolescent 
Psychiatry, 35, 1575-1583. 

Birmaher, B., Ryan, N. D., WiUiamson, D. E., Brent, D. A., 
Kaufman, J., Dahl, R. E., Perel, J., & Nelson, B. (1996b). 
Childhood and adolescent depression: A review of the 
past 10 years. Part I. Journal of the American Academy of 
Child and Adolescent Psychiatry, 35, 1427-1439. 

Black, B., Leonard, H. L., & Rapoport, J. L. (1997). Specific 
phobia, panic disorder, social phobia, and selective 
mutism. In J. M. Weiner (Ed.), Textbook of child and 
adolescent psychiatry (2nd ed., pp. 491-506). 
Washington, DC: American Academy of Child and 
Adolescent Psychiatry, American Psychiatric Press. 

Blackman, M., Eustace, J., & Chowdhury, T. (1991). 
Adolescent residential treatment: A one to three year 
follow-up. Canadian Journal of Psychiatry, 36, A11-A19. 

Bleach, B., & Clairbom, W. L. (1974). Initial evaluation of 
hot-line telephone crisis centers. Community Mental 
Health Journal, 10, 387-394. 

Bogart, N. (1988). A comparative study of behavioral 
adjustment between therapeutic and regular foster care 
in the treatment of child abuse and neglect. Unpublished 
doctoral dissertation, Memphis State University, 
Memphis, TN. 

Boothroyd, R. A., Evans, M. E., & Armstrong, M. I. (1995). 
Findings from the New York State home based crisis 
intervention program. In C. J. Liberton, K. K. Kutash, & 
R. M. Friedman (Eds.), The 7th annual research 
conference proceedings, a system of care for children 's 
mental health: Expanding the research base (pp. 25-30). 
Tampa FL: University of South Florida, Florida Mental 
Health Institute, Research and Training Center for 
Children's Mental Health. 

Boothroyd, R. A., Kuppinger, A. D., Evans, M. E., 
Armstrong, M. I., & Radigan, M. (1998). Understanding 
respite care use by families of children receiving short- 
term, in-home psychiatric emergency services. Journal of 
Child and Family Studies, 7, 353-376. 

Borduin, C. M., Henggeler, S. W., Blaske, D. M., & Stein, R. 
(1990). Multisystemic treatment of adolescent sexual 
offenders. International Journal of Offender Therapy and 
Comparative Criminology, 35, 105-114. 

Borduin, C. M., Mann, B. J., Cone, L. T., Henggeler, S. W., 
Fucci, B. R., Blaske, D. M., & WiUiams, R. A. (1995). 
Multisystemic treatment of serious juvenile offenders: 
Long-term prevention of criminaUty and violence. Journal 
of Consulting and Clinical Psychology, 63, 569-578. 



Botvin, G. J., Baker, E., Dusenbury, L., Botvin, E. M., & Diaz, 
T. (1995). Long-term follow-up results of a randomized 
drug abuse prevention trial in a white middle-class 
population. Journal of the American Medical Association, 
273, 1106-1112. 

Bowlby, J . ( 1 95 1 ) . Maternal care and mental health. Geneva: 
World Health Organization. 

Bowlby, J. (1969). Attachment and loss. Vol. 1: Attachment. 
London: Hogarth Press. 

Bowlby, J. (1988). Developmental psychiatry comes of age. 
American Journal of Psychiatry, 145, 1-10. 

Boyd, J. H. (1983). The increasing rate of suicide by firearms. 
New England Journal of Medicine, 308, 872-874. 

Boyd, J. H., & Moscicki, E. K. (1986). Firearms and youth 
suicide. American Journal of Public Health, 76, 
1240-1242. 

Bradley, W. (1937). The behavior of children receiving 
benzedrine. American Journal of Psychiatry, 94, 
577-585. 

Brent, D. A., Holder, D., Kolko, D., Birmaher, B., Baugher, 
M., Roth, C, Iyengar, S., & Johnson, B. A. (1997). A 
clinical psychotherapy trial for adolescent depression 
comparing cognitive, family, and supportive therapy. 
Archives of General Psychiatry, 54, 877-885. 

Brent, D. A., Moritz, G., Bridge, J., Perper, J., & Canobbio, 
R., (1996). Long-term impact of exposure to suicide: A 
three-year controlled follow-up. Journal of the American 
Academy of Child and Adolescent Psychiatry, 35, 
646-653. 

Brent, D. A., Perper, J. A., & Allman, C. J. (1987). Alcohol, 
firearms, and suicide among youth. Temporal trends in 
Allegheny County, Pennsylvania, 1960 to 1983. Journal 
of the American Medical Association, 257, 3369-3372. 

Brent, D. A., Perper, J. A., Allman, C. J., Moritz, G. M., 
Wartella, M. E., & Zelenak, J. P. (1991). The presence 
and accessibility of firearms in the homes of adolescent 
suicides. A case-control study. Journal of the American 
Medical Association, 266, 2989-2995. 

Brent, D. A., Perper, J. A., Goldstein, C. E., Kolko, D. J., 
Allan, M. J., Allman, C. J., & Zelenak, J. P. (1988). Risk 
factors for adolescent suicide. A comparison of adolescent 
suicide victims with suicidal inpatients. Archives of 
General Psychiatry, 45, 581-588. 

Brent, D. A., Perper, J., Moritz, G., Allman, C, Friend, A., 
Schweers, J., Roth, C, Balach, L., & Harrington, K. 
(1992). Psychiatric effects of exposure to suicide among 
the friends and acquaintances of adolescent suicide 
victims. Journal of the American Academy of Child and 
Adolescent Psychiatry, 31, 629-639. 

Brent, D. A., Perper, J. A., Moritz, G., Liotus, L., Schweers, 
J., Balach, L., & Roth, C. (1994). Familial risk factors for 
adolescent suicide: A case-control study. Acta 
Psychiatrica Scandinavica, 89, 52-58. 



196 



Children and Mental Health 



Brestan, E. V., & Eyberg, S. M. (1998). Effective 
psychosocial treatments of conduct-disordered children 
and adolescents: 29 years, 82 studies, and 5,272 kids. 
Journal of Clinical Child Psychology, 27, 180-189. 

Bridgeman, D. L. (1981). Enhanced role-taking through 
cooperative interdependence: A field study. Child 
Development, 51, 1231-1238. 

Briggs, H., Koroloff, N., & Carrock, S. (1994). The driving 
force: The influence of statewide family networks on 
family support and systems of care. Statewide family 
advocacy organization demonstration project (Final 
Report 10/90-9/93). Portland, OR: Portland State 
University, Research and Training Center on Family 
Support and Children's Mental Health. 

Briones, D. F., Heller, P. L., Chalfant, H. P., Roberts, A. E., 
Aguirre-Hauchbaum, S. F., & Farr, W. F., Jr. (1990). 
Socioeconomic status, ethnicity, psychological distress, 
and readiness to utilize a mental health facility. American 
Journal of Psychiatry, 147, 1333-1340. 

Brooks-Gunn, J., McCarton, C. M., Casey, P. H., McCormick, 
M. C, Bauer, C. R., Bembaum, J. C, Tyson, J., Swanson, 
M., Bennett, F. C, Scott, D. T., Tonascia, J., & Meinert, 
C. L. (1994a). Early intervention in low-birth-weight 
premature infants. Results through age 5 years from the 
Infant Health and Development Program. Journal of the 
American Medical Association, 272, 1257-1262. 

Brooks-Gunn, J., McCormick, M. C, Shapiro, S., Benasich, 
A., & Black, G. W. (1994b). The effects of early 
education intervention on maternal employment, pubUc 
assistance, and health insurance: The infant health and 
development program. American Journal of Public 
Health, 84,924^931. 

Broskowski, A., & Harshberger, D. (1998). Predicting costs 
when working with the Medicaid population. In K. 
Coughlin (Ed.), Medicaid managed care sourcebook (pp. 
215-224). New York: Faulkner & Gray. 

Brown, J. (1987). A review of meta-analyses conducted on 
psychotherapy outcome research. Clinical Psychology 
Review, 7, 1-23. 

Bruner, J. S. (1971). The relevance of education. New York: 
Norton. 

Brunk, M., Henggeler, S. W., & Whelan, J. P. (1987). 
Comparison of multisystemic therapy and parent training 
in the brief treatment of child abuse and neglect. Journal 
of Consulting and Clinical Psychology, 55, 171-178. 

Bruns, E. J., Burchard, J. D., & Yoe, J. T. (1995). Evaluating 
the Vermont system of care: Outcomes associated with 
community-based wraparound services. Journal of Child 
and Family Studies, 4, 321-329. 

Bryson, S. E., & Smith, I. M. (1998). Epidemiology of autism: 
Prevalence, associated characteristics, and service 
delivery. Mental Retardation and Developmental 
Disabilities Research Reviews, 4, 97-103. 



Bui, K. v., & Takeuchi, D. T. (1992). Ethnic minority 
adolescents and the use of community mental health care 
services. American Journal of Community Psychology, 
20, 403-417. 

Bums, B. J. (1991). Mental health service use by adolescents 
in the 1970s and 1980s. Journal of the American 
Academy of Child and Adolescent Psychiatry, 30, 
144-150. 

Bums, B. J., Costello, E. J., Angold, A., Tweed, D., Stangl, 
D., Farmer, E. M., & Erkanli, A. (1995a). Children's 
mental health service use across service sectors. Health 
Affairs (Millwood), 14, 147-159. 

Bums, B. J., Farmer, E. M. Z., Angold, A., Costello, E. J., & 
Behar, L. (1996). A randomized trial of case management 
for youths with serious emotional disturbance. Journal of 
Clinical Child Psychology, 25, 476-486. 

Bums, B. J., & Goldman, S. K. (Eds.). (1999). Promising 
practices in wraparound for children with severe 
emotional disturbance and their families. Systems of care: 
Promising practices in children's mental health (1998 
Series, Vol. IV). Rockville, MD: Center for Mental 
Health Services. 

Bums, B. J., Hoagwood, K. & Maultsby, L. T. (1998). 
Improving outcomes for children and adolescents with 
serious emotional and behavioral disorders: Current and 
future directions. In M. H. Epstein, K. Kutash, & A. J. 
Duchnowski (Eds.), Outcomes for children and youth 
with emotional and behavioral disorders and their 
families: Programs and evaluation best practices (pp. 
686-707). Austin, TX: Pro-Ed. 

Bussing, R., Zima, B., & Fomess, S. R. (1998a). Children who 
quaUfy for LD and SED programs: Do they differ in level 
of ADHD symptoms and comorbid psychiatric 
conditions? Behavioral Disorders, 23, 85-97. 

Bussing, R., Zima, B. T., Perwien, A. R., BeUn, T. R., & 
Widawski, M. (1998b). Children in special education 
programs: Attention deficit hyperactivity disorder, use of 
services, and unmet needs. American Journal of Public 
Health, 88, 880-886. 

Campbell, F. A., & Ramey, C. T. (1994). Effects of early 
intervention on intellectual and academic achievement: A 
follow-up study of children from low-income families. 
Child Development, 65, 684-698. 

Campbell, M., Adams, P. B., Small, A. M., Kafantaris, V., 
Silva, R. R., Shell, J., Perry, R., & Overall, J. E. (1995). 
Lithium in hospitalized aggressive children with conduct 
disorder: A double-blind and placebo-controlled study. 
Journal of the American Academy of Child and 
Adolescent Psychiatry, 34, 445^53. 

Campbell, M., Armenteros, J. L., Malone, R. P., Adams, P. B., 
Eisenberg, Z. W., & Overall, J. E. (1997). Neuroleptic- 
related dyskinesias in autistic children: A prospective, 
longitudinal study. Journal of the American Academy of 
Child and Adolescent Psychiatry, 36, 835-843. 



197 



Mental Health: A Report of the Surgeon General 



Campbell, M., & Cueva, J. E. (1995). Psychopharmacology in 
child and adolescent psychiatry: A review of the past 
seven years. Part II. Journal of the American Academy of 
Child and Adolescent Psychiatry, 34, 1262-1272. 

Campbell. M., Rapoport, J. L., & Simpson, G. M. (1999). 
Antipsychotics in children and adolescents. Journal of 
American Academy of Child and Adolescent Psychiatry, 
38, 537-545. 

Campos, J., Barrett, K. C, & Lamb, M. E. (1983). Socio- 
emotional development. In M. Haith & J. Campos (Eds.), 
Handbook of child psychology (4th ed., pp. 139). New 
York: Wiley. 

Canino, I. A., Gould, M. S., Prupis, S., & Shaffer, D. (1986). 
A comparison of symptoms and diagnoses in Hispanic 
and black children in an outpatient mental health clinic. 
Journal of the American Academy of Child Psychiatry, 
25, 254-259. 

Cantwell, D. P. (1996). Attention deficit disorder: A review of 
the past 10 years. Journal of the American Academy of 
Child and Adolescent Psychiatry, 35, 978-987. 

Cantwell, D. P. (1998). ADHD through the life span: The role 
of bupropion in treatment. Journal of Clinical Psychiatry, 
59(Suppl. 4), 92-94. 

Carlson, C. L., Pelham, W. E., Jr., Milich, R., & Dixon, J. 
(1992). Single and combined effects of methylphenidate 
and behavior therapy on the classroom performance of 
children with attention-deficit hyperactivity disorder. 
Journal of Abnortnal Child Psychology, 20, 213-232. 

Carlson, E. A., Jacobvitz, D., & Sroufe, L. A. (1995). A 
developmental investigation of inattentiveness and 
hyperactivity. Child Development, 66, 37-54. 

Carlsten, A., Allebeck, P., & Brandt, L. (1996). Are suicide 
rates in Sweden associated with changes in the 
prescribing of medicines? Acta Psychiatrica 
Scandanavica, 94, 94-100. 

Casey, P. H., Kelleher, K. J., Bradley, R. H., Kellogg, K. W., 
Kirby, R. S., & Whiteside, L. (1994). A multifaceted 
intervention for infants with failure to thrive. A 
prospective study. Archives of Pediatrics and Adolescent 
Medicine, 148, 1071-1077. 

Casey, R. J., & Berman, J. S. (1985). The outcome of 
psychotherapy with children. Psychological Bulletin, 98, 
388^00. 

Catron, T., & Weiss, B. (1994). The Vanderbilt school-based 
counseling program. Journal of Emotional and 
Behavioral Disorders, 2, 247-253. 

Cauce, A. M., Morgan, C. J., Wagner, V., Moore, E., Sy, J., 
Wurzbacher, K., Weeden K., Tomlin, S., & Blanchard, T. 
(1994). Effectiveness of intensive case management for 
homeless adolescents: Results of a three month follow-up. 
Journal of Emotional and Behavioral Disorders, 2, 
219-227. 



Centers for Disease Control and Prevention. (1998). Youth 

risk behavior surveillance — United States, 1997. CDC 

Sun'eillance Summaries, August 14, 1998. MMWR, 47 

(No. SS-3). 
Centers for Disease Control and Prevention. (1999). Suicide 

deaths and rates per 100,000 [On-line]. Available: 

http://www.cdc.gov/ncipc/data/us9794/suic.htm 
Chamberlain, P., & Reid, J. B. (1991). Using a speciaHzed 

foster care community treatment model for children and 

adolescents leaving the state mental hospital. Journal of 

Community Psychology, 19, 266-276. 
Chamberlain, P., & Reid, J. B. (1998). Comparison of two 

community alternatives to incarceration for chronic 

juvenile offenders. Journal of Consulting and Clinical 

Psychology, 66, 624-633. 
Chamberlain, P., & Weinrott, M. (1990). Specialized foster 

care: Treating seriously emotionally disturbed children. 

Child Today, 19, 24-27. 
Chess, S., Fernandez, P., & Kom, S. (1978). Behavioral 

consequences of congenital rubella. Journal of Pediatrics, 

93, 699-703. 
Chess, S., & Thomas, A. (1984). Origins and evolution of 

behavior disorders: From infancy to early adult life. New 

York: Bmnner/Mazel. 
Chomsky. N. (1965). Aspects of a theory of syntax. 

Cambridge, MA: MIT Press. 
Chomsky, N. (1975). Reflections on language. New York: 

Pantheon Books. 
Chomsky, N. (1986). Knowledge of language: Its nature, 

origins, and use. New York: Praeger. 
Cicchetti, D., & Carlson, V. (Eds.). (1989). Child 

maltreatment: Theory and research on the causes and 

consequences of child abuse and neglect. New York: 

Cambridge University Press. 
Cicchetti, D., & Cohen, D. J. (1995). Developmental 

psychopathology. New York: John Wiley. 
Cicchetti, D., & Toth, S. L. (1998). The development of 

depression in children and adolescents. American 

Psychologist, 53, 221-241. 
Clark, D. C, & Goebel, A. E. (1996). SibUngs of youth 

suicide victims. In C. Pfeffer (Ed.), Severe stress and 

mental disturbance in children (pp. 361-389). 

Washington, DC: American Psychiatric Press. 
Clark, H. B., Prange, M. E., Lee, B., Boyd, L. A., McDonald, 

B. A., & Stewart, E. S. (1994). Improving adjustment 

outcomes for foster children with emotional and 

behavioral disorders: Early findings from a controlled 

study on individualized services. Journal of Emotional 

and Behavioral Disorders, 2, 207-218. 



198 



Children and Mental Health 



Clark, H.B., Prange, M., Lee, B., Stewart, E., McDonald, B., 
& Boyd, L. (1998). An individualized wraparound 
process for children with emotional/behavioral 
disturbances: FoUow-up findings and impUcations from a 
controlled study. In M. H. Epstein, K. Kutash, & A. J. 
Duchnowski (Eds.), Outcomes for children and youth 
with emotional and behavioral disorders and their 
families: Programs and evaluation best practices (pp. 
686-707). Austin, TX: Pro-Ed. 

Clarke, G. N., Hops, H., Lewinsohn, P. M., Andrews, J., 
Seeley, J. R., & Williams, J. (1992). Cognitive -behavioral 
group treatment of adolescent depression: Prediction of 
outcome. Behavior Therapy, 23, 341-354. 

Claussen, J. M., Landsverk, J., Ganger, W., Chadwick, D., & 
Litronik, A. (1998). Mental health problems of children in 
foster care. Journal of Child and Family Studies, 7, 
283-296. 

Clein, P. D., & Riddle, M. A. (1996). Pharmacokinetics in 
children and adolescents. In M. Lewis (Ed.), Child and 
adolescent psychiatry: A comprehensive textbook (2nd 
ed., pp. 765-772). Baltimore: WiUiams & Wilkins. 

Cohen, R., Harris, R., Gottlieb, S., & Best, A. M. (1991). 
States' use of transfer of custody as a requirement for 
providing services to emotionally disturbed children. 
Hospital and Community Psychiatry, 42, 526-530. 

Cohen, R., Parmelee, D. X., Irwin, L., Weisz, J. R., Howard, 
P., Purcell, P., & Best, A. M. (1990). Characteristics of 
children and adolescents in a psychiatric hospital and a 
corrections facility. Journal of the American Academy of 
Child and Adolescent Psychiatry, 29, 909-913. 

Cohen, S., & Wills, T. A. (1985). Stress, social support, and 
the buffering hypothesis. Psychological Bulletin, 98, 
310-357. 

Cohn, J. F., Matias, R., Tronick, E. Z., Council, D., & Lyons- 
Ruth, K. (1986). Face-to-face interactions of depressed 
mothers and their infants. New Directions for Child 
Development, 34, 31^5. 

Coie, J. D., & Kupersmidt, J. B. (1983). A behavioral analysis 
of emerging social status in boys' groups. Child 
Development, 54, 1400-1416. 

Coker, C. C, Menz, F. E., Johnson, L. A., & McAlees, D. C. 
(1998). School Outcomes and Community Benefits for 
Minority Youth with Serious Disturbances: A Synthesis of 
the Research Literature. Menomonie, WI: University of 
Wisconsin-Stout, The Rehabilitation Research and 
Training Center. 

Cole, R. F. (1990). Financing policy and administrative 
mechanisms for child and adolescent mental health 
services. The Child, Youth, and Family Quarterly, 13. 

Conduct Problems Prevention Research Group. (1999a). Initial 
impact of the fast track prevention trial for conduct 
problems: I. The high-risk sample. Journal of Consulting 
and Clinical Psychology, 67, 631-647. 



Conduct Problems Prevention Research Group. (1999b). 
Initial impact of the fast track prevention trial for conduct 
problems: 11. Classroom effects. Journal of Consulting 
and Clinical Psychology, 67, 648-657. 

Cook, E. H., Jr. (1998). Genetics of autism. Mental 
Retardation and Developmental Disabilities Research 
Reviews, 4, 113-120. 

Cook, E. H., Jr., Stein, M. A., Krasowski, M. D., Cox, N. J., 
Olkon, D. M., Kieffer, J. E., & Leventhal, B. L. (1995). 
Association of attention-deficit disorder and the dopamine 
transporter gene. American Journal of Human Genetics, 
56, 993-998. 

Costello, E. J., Angold, A., Bums, B. J.. Stangl, D. K., Tweed, 
D. L., Erkanli, A., & Worthman, C. M. (1996). The Great 
Smoky Mountains Study of Youth. Goals, design, 
methods, and the prevalence of DSM-III-R disorders. 
Archives of General Psychiatry, 53, 1 129-1 136. 

Costello, E. J., & Janiszewski, S. (1990). Who gets treated? 
Factors associated with referral in children with 
psychiatric disorders. Acta Psychiatrica Scandinavica, 81, 
523-529. 

Council of Scientific Affairs. (1991). Hispanic health in the 
United States. Journal of the American Medical 
Association, 265, 248-252. 

Cowen, E. L., Hightower, A. D., Pedro-Carroll, J. P., Work, 
W. C, Wyman, P. A., and Haffey, W. G. (1996). School- 
based prevention for children at risk: The primary mental 
health project. Washington, DC: American Psychological 
Association. 

Cross, T., Bazron B., Dennis, K., & Isaacs, M. (1989). 
Towards a culturally competent system of care: A 
monograph on effective services for minority children 
who are severely emotionally disturbed. Washington, DC: 
Georgetown University Child Development Center. 

Crowley, M. J., & Kazdin, A. E. (1998). Child psychosocial 
functioning and parent quahty of Ufe among clinically 
referred children. Journal of Child and Family Studies, 7, 
233-251. 

Cummings, P., Grossman, D. C, Rivara, F. P., & Koepsell, T. 
D. (1997). State gun safe storage laws and child mortality 
due to firearms. Journal of the American Medical 
Association, 278, 1084-1086. 

Curry, J. F. (1991). Outcome research on residential treatment: 
Implications and suggested directions. American Journal 
of Orthopsychiatry, 61, 348-357. 

Curtis, I. W., & Singh, N. N. (1996). Family involvement and 
empowerment in mental health service provision for 
children with emotional and behavioral disorders. Journal 
of Child and Family Studies, 5, 503-517. 

Curtiss, S. (1977). Genie: A psychological study of a modem- 
day wild child. New York: Academy Press. 

Dasen, P. R., Berry, J. W., & Sartorius, N. (1988). Health and 
cross-cultural psychology. Newbury Park, CA: Sage. 



199 



Mental Health: A Report of the Surgeon General 



Davidson, L. E. (1989). Suicide clusters and youth. In C. R. 
Pfeffer (Ed.), Suicide among youth: Perspectives on risk 
and prevention (pp. 83-89). Washington, DC: American 
Psychiatric Press. 

Dawson, G., & Osteriing, J. (1997). In M. J. Guralnick (Ed.). 
The effectiveness of early intervention (pp. 307-325). 
Baltimore: Paul H. Brookes. 

de Long, M. L. (1992). Attachment, individuation, and risk of 
suicide in late adolescence. Journal of Youth and 
Adolescence, 21, 357-373. 

de Wilde, E. J., Kienhorst, I. C, Diekstra, R. P., & Wolters, 
W. H. (1992). The relationship between adolescent 
suicidal behavior and life events in childhood and 
adolescence. American Journal of Psychiatry, 149, 
45-51. 

Dennis, W. (1973). Children of the creche. New York: 
Appleton-Century-Crofts. 

DeVeaugh-Geiss, J., Moroz, G., Biederman, J., Cantwell, D., 
Fontaine, R., Greist, J. H., Reichler, R., Katz, R., & 
Landau, P. (1992). Clomipramine hydrochloride in 
childhood and adolescent obsessive-compulsive 
disorder — a multicenter trial. Journal of the American 
Academy of Child and Adolescent Psychiatry, 31, 45^9. 

DevUn, M. J. (1996). Assessment and treatment of binge- 
eating disorder. Psychiatric Clinics of North America, 19, 
761-772. 

Dodge, K. A. (1983). Behavioral antecedents of peer social 
status. Child Development, 54, 1386-1399. 

Dodge, K. A., & Feldman, E. (1990). Issues in social 
cognition and sociometric status. In S. R. Asher & J. D. 
Coie (Eds.), Peer rejection in childhood (pp. 119-155). 
Cambridge, MA: Cambridge University Press. 

Dodge, K. A., Bates, J. E., & Pettit, G. S. (1990). Mechanisms 
in the cycle of violence. Science, 250, 1678-1683. 

Douglas, V. I., & Peters, K. G. (1979). Toward a clearer 
definition of the attentional deficit of hyperactive 
children. In E. A. Hale & M. Lewis (Eds.), Attention and 
the development of cognitive skills (pp. 173-247). New 
York: Plenum. 

Downey, G., & Coyne, J. C. (1990). Children of depressed 
parents: An integrative review. Psychological Bulletin, 
108, 50-76. 

Dreier, M. P., & Lewis, M. G. (1991). Support and 
psychoeducation for parents of hospitalized mentally ill 
children. Health and Social Work, 16, 11-18. 

DSM-III. See American Psychiatric Association (1980). 

DSM-HI-R. See American Psychiatric Association (1987). 

DSM-IV. See American Psychiatric Association (1994). 

Duchnowski, A. J., Hall, K. W., Kutash, K., & Friedman, R. 
M. (1998). The alternatives to residential treatment 
studies. In M. H. Epstein, K. Kutash, & A. J. Duchnowski 
(Eds.), Outcomes for children and youth with behavioral 
and emotional disorders and their families (pp. 55-80). 
Austin, TX: Pro-Ed. 



Dutton, D. B. (1986). Social class, health and illness. In L. H. 
Aiken & D. Mechanic (Eds.), Applications of social 
science to clinical medicine and health policy (pp. 
31-62). New Brunswick, NJ: Rutgers University. 

Eisen, S. V., Griffin, M., Sederer, L. I., Dickey, B., & Mhin, 
S. M. (1995). The impact of preadmission approval and 
continued stay review on hospital stay and outcome 
among children and adolescents. Journal of Mental 
Health Administration, 22, 270-277. 

Eisenberg, L. (1957). Psychiatric implication of damage in 
children. Psychiatric Quarterly, 31, 72-92. 

Eisenberg, L. (1996). Commentary. What should doctors do in 
the face of negative evidence? Journal of Nervous and 
Mental Disease, 184, 103-105. 

Elia, J., Borcherding, B. G., Rapoport, J. L., & Keysor, C. S. 
(1991). Methylphenidate and dextroamphetamine 
treatments of hyperactivity: Are there true nonresponders? 
Psychiatry Research, 36, 141-155. 

Elia, J., & Rapoport, J. L. (1991). Ritalin versus 
dextroamphetamine in ADHD: Both should be tried. In L. 
L. Greenhill & B. B. Osman (Eds.), Ritalin: Theory and 
patient management (pp. 69-74). New York: Mary Ann 
Liebert. 

Elliot, D. J., Koroloff, N. M., Koren, P. E., & Freisen, B. J. 
(1998). Improving access to children's mental health 
services: The family associate approach. In M. H. Epstein, 
K. Kutash, & A. J. Duchnowski (Eds.), Outcomes for 
children and youth with emotional and behavioral 
disorders and their families: Programs and evaluation 
best practices (pp. 581-609). Austin, TX: Pro-Ed. 

Emslie, G. J., Weinberg, W. A., Kowatch, R. A., Hughes, C. 
W., Carmody, T. J., & Rush, A. J. (1997). Huoxetine 
treatment of depressed children and adolescents. Archives 
of General Psychiatry, 54, 1031-1037. 

EmsUe, G. J., Walkup, J. T., Pliszka, S. R., & Ernest, M. 
(1999). Nontricyclic antidepressants: Current trends in 
children and adolescents. Journal of the American 
Academy of Child and Adolescent Psychiatry, 38, 
517-528. 

Esser, G., Schmidt, M. H., & Woemer, W. (1990). 
Epidemiology and course of psychiatric disorders in 
school-age children — results of a longitudinal study. 
Journal of Child Psychology and Psychiatry, 31, 
243-263. 

Essock, S., M., & Goldman, H. H. (1995). States' embrace of 
managed mental health care. Health Affairs, 14, 34-44. 

Evans, M. E., Armstrong, M., & Kuppinger, A. (1996a). 
Family-centered intensive case management: A step 
toward understanding individualized care. Journal of 
Child and Family Studies, 5, 55-65. 

Evans, M. E., Banks, S. M., Huz, S., & McNulty, T. L. (1994). 
Initial hospitaUzation and community tenure outcomes for 
intensive case management for children and youth with 
serious emotional disturbance. Journal of Child and 
Family Studies, 3, 225-234. 



200 



Children and Mental Health 



Evans, M. E., Dollard, N., & McNulty, T. L. (1992). 
Characteristics of seriously emotionally disturbed youth 
with and without substance abuse in intensive case 
management. Journal of Child and Family Studies, I, 
305-314. 

Evans, M. E., Huz, S., McNulty, T., & Banks, S. M. (1996b). 
Child, family, and system outcomes of intensive case 
management in New York State. Psychiatric Quarteriy, 
67, 273-287. 

Eyberg, S. M., & Robinson, E. A. (1983). Conduct problem 
behavior: Standardization of a behavioral rating scale with 
adolescents. Journal of Clinical Child Psychology, 12, 
347-354. 

Fairbum, C. G., Jones, R., Peveler, R. C, Hope, R. A., & 
O'Connor, M. (1993). Psychotherapy and buUmia 
nervosa. Longer-term effects of interpersonal 
psychotherapy, behavior therapy, and cognitive behavior 
therapy. Archives of General Psychiatry, 50, 419-428. 

Famularo, R., Kinscherff, R., & Fenton, T. (1992). Psychiatric 
diagnoses of maltreated children: Prehminary findings. 
Journal of American Academy of Child and Adolescent 
Psychiatry^ 31, 863-867. 

Farberow, N. R. (1985). Youth suicide: An international 
problem. Report of the National Conference on Youth 
Suicide. Washington, DC: Youth Suicide National Center. 

Farmer, E. M. Z., Bums, B. J., Angold, A., & Costello, E. J. 
(1997). Impact of children's mental health problems on 
families: Relationships with service use. Journal of 
Emotional and Behavioral Disorders, 5, 230-238. 

Feil, E. G., Walker, H. M., & Severson, H. H. (1995). The 
early screening project for young children with behavior 
problems. Journal of Emotional and Behavioral 
Disorders, 3, 194-202. 

Feldman, R. A., Caplinger, T. E., & Wodarski, J. S. (1983). 
The St Louis conundrum: The effective treatment of 
antisocial youths. Englewood Cliffs, NJ: Prentice-HaU. 

Feldman, S. (1997). The Fort Bragg demonstration and 
evaluation. y4menca« Psychologist, 52, 560-561. 

Field, T., Healy, B., Goldstein, S., & Guthertz, M. (1990). 
Behavior-state matching and synchrony in mother-infant 
interactions of non-depressed versus depressed dads. 
Developmental Psychology, 26, 7-14. 

Firestone, P., Crowe, D., Goodman, J. T., & McGrath, P. 
(1986). Vicissitudes of follow-up studies: Differential 
effects of parent training and stimulant medication with 
hyperactives. American Journal of Orthopsychiatry, 56, 
184-194. 

Flament, M. F., Rapoport, J. L., Berg, C. J., Sceery, W., Kilts, 
C, Mellstrom, B., & Linnoila, M. (1985). Clomipramine 
treatment of childhood obsessive-compulsive disorder. A 
double-blind controlled study. Archives of General 
Psychiatry, 42, 977-983. 



Flament, M. F., Whitaker, A., Rapoport, J. L., Davies, M., 
Berg, C. Z., Kalikow, K., Sceery, W.. & Shaffer, D. 
(1988). Obsessive compulsive disorder in adolescence: 
An epidemiological study. Journal of the American 
Academy of Child and Adolescent Psychiatry, 27, 
16A^11\. 

Fleming, J. E., Boyle, M. H., & Offord, D. R. (1993). The 
outcome of adolescent depression in the Ontario Child 
Health Study follow-up. Journal of the American 
Academy of Child and Adolescent Psychiatry, 32, 28-33. 

Flomenhaft, K. (1974). Outcome of treatment for adolescents. 
Adolescence, 9, 57-66. 

Food and Drug Administration. (1998). The CDER handbook 
[On-line]. Available: http://www.fda/cder/ 
handbook/index 

Food and Drug Administration. (1999). The FDA 
modernization act of 1997 [On-hne]. Available: 
http://www.fda.gov/cder/fdama/default.htm 

FosterFamdly-BasedTreatment Association. (1995). Program 
standards for treatment foster care. New York: Author. 

Eraser, M. W., Nelson, K. E., & Rivard, J. C. (1997). 
Effectiveness of family preservation services. Social Work 
Research, 21, 138-153. 

Eraser, M. W., Walton, E., Lewis, R. E., Pecora, P. J., & 
Walton, W. K. (1996). An experiment in family 
reunification: Correlates of outcomes at one-year follow- 
up. Children and Youth Services Review, 18, 335-361. 

Freud, A. (1965). The concept of the rejecting mother. In The 
writings of Anna Freud (Vol. 4, rev. ed., pp. 586-602). 
New York: International Universities Press. 

Friday, P. C, & Hage, J. (1976). Youth crime in postindustrial 
societies: An integrated perspective. Criminology, 14, 
347-368. 

Friedman, R. M., & Bums, B. J. (1996). The evaluation of the 
Fort Bragg Demonstration Project: An alternative 
interpretation of the findings. Journal of Mental Health 
Administration, 23, 128-136. 

Friedman, R., Katz-Leavy, J., Manderscheid, R., & 
Sondheimer, D. (1996a). Prevalence of serious emotional 
disturbance in children and adolescents. In R. W. 
Manderscheid & M. A. Sonnenschein (Eds.), Mental 
health, United States, 799(5(pp. 77-91). Washington, DC: 
U.S. Govemment Printing Office. 

Friedman, R. M., Katz-Leavy, J. W., Manderscheid, R. W., & 
Sondheimer, D. L. (1998). Prevalence of serious 
emotional disturbance in children and adolescents. An 
update. In R. W. Manderscheid & M. A. Sonnenschein 
(Eds.), Mental health, United States, 1998 (pp. 110-112). 
Washington, DC: U.S. Govemment Printing Office 

Friedman, R. M., & Kutash, K. (1986). Mad, bad, sad, can't 
add? Florida Adolescent and Child Treatment Study 
(FACTS). Tampa, FL: University of South Florida, Louise 
de la Parte Florida Mental Health Institute. 



201 



Mental Health: A Report of the Surgeon General 



Friedman, R. M., Kutash, K., & Duchnowski, A. J. (1996b). 
The population of concern: Defining the issues. In B. A. 
Stroul (Ed.), Children's mental health: Creating systems 
of care in a changing society (pp. 69-96). Baltimore: Paul 
H. Brookes. 

Friedman, R. M., & Street, S. (1985). Admission and 
discharge criteria for children's mental health services: A 
review of the issues. Journal of Clinical Child 
Psychology, 14, 229-235. 

Friesen, B. J. (1990). National study of parents whose children 
have serious emotional disorders: Preliminary findings. In 
A. Algarin, R. Friedman, A. Duchnowski, K. Kutash, S. 
Silver, & M. Johnson (Eds.), Second annual conference 
proceedings on children's mental health services and 
policy: Building a research base (pp. 29^14). Tampa, FL: 
University of South Florida, Florida Mental Health 
Institute, Research and Training Center for Children's 
Mental Health. 

Friesen, B. J., & Koroloff, N. M. (1990). Family-centered 
services: Implications for mental health administration 
and research. Journal of Mental Health Administration, 
17, 13-25. 

Friesen, B. J., & Stephens, B. (1998). Expanding family roles 
in the system of care: Research and practice. In M. R. 
Epstein, K. Kutash, & A. J. Duchnowski (Eds.), 
Outcomes for children and youth with behavioral and 
emotional disorders and their families: Programs and 
evaluation, best practices (pp. 231-259). Austin, TX: 
Pro-Ed. 

Fristad, M. A., Gavazzi, S. M., Centolella, D. M., & Solkano, 
K. W. (1996). Psycho-education: A promising 
intervention strategy for families of children and 
adolescents with mood disorders. Contemporary Family 
Therapy: An International Journal, 18, 371-384. 

Gabel, S., & Finn, S. (1986). Outcome in children's day- 
treatment programs. International Journal of Partial 
Hospitalization, 3, 261-271. 

Gadow, K. D., Sverd, J., Sprafkin, J., Nolan, E. E., & Ezor, S. 
N. (1995). Efficacy of methylphenidate for attention- 
deficit hyperactivity disorder in children with tic disorder. 
Archives of General Psychiatry, 52, 444-455. 

Garber, J., & Hilsman, R. (1992). Cognition, stress, and 
depression in children and adolescents. Child and 
Adolescent Psychiatric Clinics of North America, 1, 
129-167. 

Garber, J., Kriss, M. R., Koch, M., & Lindholm, L. (1988). 
Recurrent depression in adolescents: A follow-up study. 
Journal of the American Academy of Child and 
Adolescent Psychiatry, 27, 49-54. 

Garmezy, N. (1983). Stressors of childhood. In N. Garmezy & 
M. Rutter (Eds.), Stress, coping, and development in 
children (pp. 43-84). New York: McGraw-Hill. 



Garofalo, R., Wolf, R. C, Kessel, S., Palfrey, J., & DuRant, 
R. H. (1998). The association between health risk 
behaviors and sexual orientation among a school-based 
sample of adolescents. Pediatrics, 101 , 895-902. 

Garofalo, R., Wolf, R. C, Wissow, L. S., Woods, E. R., & 
Goodman, E. (1999). Sexual orientation and risk of 
suicide attempts among a representative sample of youth. 
Archives of Pediatrics & Adolescent Medicine, 153, 
487^93. 

Garrison, C. Z., Waller, J. L., Cuffee, S. P., McKeown, R. E., 
Addy, C. L., & Jackson, K. L. (1997). Incidence of major 
depressive disorder and dysthymia in young adolescents. 
Journal of the American Academy of Child and 
Adolescent Psychiatry, 36, 458^65. 

Garvey, M. A., Giedd, J., & Swedo, S. E. (1998). PANDAS: 
The search for environmental triggers of pediatric 
neuropsychiatric disorders. Lessons from rheumatic fever. 
Journal of Child Neurology, 13, 413^23. 

Geller, B., Cooper, T. B., Sun, K., Zimerman, B., Frazier, J., 
Williams, M., & Heath, J. (1998). Double-blind and 
placebo-controlled study of lithium for adolescent bipolar 
disorders with secondary substance dependency. Journal 
of the American Academy of Child and Adolescent 
Psychiatry, 37, 171-178. 

Geller, B., & Luby, J. (1997). Child and adolescent bipolar 
disorder: A review of the past 10 years. Journal of the 
American Academy of Child and Adolescent Psychiatry, 
36, 1168-1176. 

General Accounting Office. (1997). Head Start: Research 
provides little information on impact of current program 
(GAO/HEHS-97-59). Washington, DC: U.S. Government 
Printing Office. 

Gill, M., Daly, G., Heron, S., Hawi, Z., & Fitzgerald, M. 
(1997). Confirmation of association between attention 
deficit hyperactivity disorder and a dopamine transporter 
polymorphism. Molecular Psychiatry, 2, 311-313. 

Gittelman, R. (1985). The use of psychological tests in clinical 
practice with children. In D. Shaffer, A. A. Ehrhardt, & L. 
L. Greenhill (Eds.), The clinical guide to child psychiatry 
(pp. 447^74). New York: Free Press. 

Gittelman, R., Abikoff, H., Pollack, E., Klein, D. F., Katz, S., 
& Mattes, J. (1980). A controlled trial of behavior 
modification and methylphenidate in hyperactive children. 
In C. K. Walen & B. Henker (Eds.), Hyperactive 
children: The social ecology of identification and 
treatment (pp. 221-243). New York: Academic Press. 

Gittelman, R., Mannuzza, S., Shenker, R., & Bonagura, N. 
(1985). Hyperactive boys almost grown up. I. Psychiatric 
status. Archives of General Psychiatry, 42, 937-947. 

Gittelman-Klein, R. (1978). Validity of projective tests for 
psychodiagnosis in children. In R. L. Spitzer & D. F. 
Klein (Eds.), Critical issues in psychiatric diagnosis (pp. 
141-165). New York: Raven Press. 



202 



Children and Mental Health 



Glisson, C. (1996). Judicial and service decisions for children 
entering state custody: The limited role of mental health. 
Social Service Review, 70, 257-28 1 . 

Goenjian, A. K., Pynoos, R. S., Steinberg, A. M., Najarian, L. 
M., Asamow, J. R., Karayan, I., Ghurabi, M., & 
Fairbanks, L. A. (1995). Psychiatric comorbidity in 
children after the 1988 earthquake in Armenia. Journal of 
American Academy of Child and Adolescent Psychiatry, 
34, 1174-1184. 

Goldman, H. H. (1998). Organizing mental health serxnces: 
An evidence-based approach. Stockholm: Swedish 
Council Medical Technology Assessment. 

Goldman, S. K., & Faw, L. (1998). Three wraparound models 
as promising approaches. In B. J. Bums & S. K. Goldman 
(Eds.). Promising practices in wraparound for children 
with severe emotional disturbance and their families. 
Systems of care: Promising practices in children 's mental 
health, 1998 Series Vol. /V(pp. 17-59). Washington, DC: 
American Institutes for Research, Center for Effective 
Collaboration and Practice. 

Goldman, L. S., Genel, M., Bezman, R. J., & Slanetz, P. J. 
(1998). Diagnosis and treatment of attention- 
deficit/hyperactivity disorder in children and adolescents. 
Council on Scientific Affairs, American Medical 
Association. Journal of the American Medical 
Association, 279, 1100-1107. 

Goldman, S. K. (1988). Series on community-based services 
for children and adolescents who are severely 
emotionally disturbed. Vol. II: Crisis services. 
Washington, DC: Georgetown Child Development 
Center, National Technical Assistance Center for 
Children's Mental Health. 

Goldsmith, H., Buss, A., Plomin, R., Rothbart, M. K., 
Thomas, A., Chess, S., Hinde, R. A., & McCall, R. B. 
(1987). Roundtable: What is temperament? Child 
Development, 58, 505-529. 

Goodman, R., & Stevenson, J. (1989). A twin study of 
hyperactivity. II. The aetiological role of genes, family 
relationships and perinatal adversity. Journal of Child 
Psychology and Psychiatry, 30, 691-709. 

Goodwin, F., & Jamison, K. (1990). Manic-depressive illness. 
London/New York: Oxford University Press. 

Gordon, C. T., State, R. C, Nelson, J. E., Hamburger, S. D., 
& Rapoport, J. L. (1993). A double-blind comparison of 
clomipramine, desipramine, and placebo in the treatment 
of autistic disorder. Archives of General Psychiatry, 50, 
441^147. 

Gould, M. S., Fisher, P., Parides, M., Flory, M., & Shaffer, D. 
(1996). Psychosocial risk factors of child and adolescent 
completed suicide. Archives of General Psychiatry, 53, 
1155-1162. 



Gould, M. S., King, R., Greenwald, S., Fisher, P., Schwab- 
Stone, M., Kramer, R., Flisher, A. J., Goodman, S., 
Canino, G., & Shaffer, D. (1998). Psychopathology 
associated with suicidal ideation and attempts among 
children and adolescents. Journal of the American 
Academy of Child and Adolescent Psychiatry, 37, 
915-923. 

Gould, M. S., & Shaffer, D. (1986). The impact of suicide in 
television movies. Evidence of imitation. New England 
Journal of Medicine, 315, 690-694. 

Grachev, I. D., Breiter, H. C, Ranch, S. L., Savage, C. R., 
Baer, L., Shera, D. M., Kennedy, D. N., Makris, N., 
Caviness, V. S., & Jenike, M. A. (1998). Structural 
abnormalities of frontal neocortex in obsessive- 
compulsive disorder [Letter]. Archives of General 
Psychiatry, 55, 181-182. 

Gratton, J., Paulson, R., Stuntzer-Gibson, D., & Summers, R. 
(1995, June). Oregon partners project: Progress and 
outcomes report. Paper presented at the Building on 
Family Strengths Conference, Portland, OR. 

Green, W. H. (1995). The treatment of attention-deficit 
hyperactivity disorder with nonstimulant medications. 
Child and Adolescent Psychiatric Clinics of North 
America, 4, 169-195. 

Green, W. H. (1996). Principles of psychopharmacotherapy 
and specific drug treatments. In M. Lewis (Ed.), Child 
and adolescent psychiatry: A comprehensive textbook 
(2nd ed., pp. 772-801). Baltimore: Williams & Wilkins. 

Greenbaum, P. E., Dedrick, R. F., Kutash, K., Brown, E. C, 
Larieri, S. P., & Pugh, A. M. (1998). National Adolescent 
and Child Treatment Study (NACTS): Outcomes for 
children with serious emotional and behavioral 
disturbance. In M. H. Epstein, K. Kutash, & A. 
Duchnowski (Eds.). Outcomes for children and youth 
with behavioral and emotional disorders and their 
families (pp. 21-54). Austin, TX: Pro-Ed. 

Greenbaum, P. E., Prange, M. E., Friedman, R. M., & Silver, 
S. E. ( 1991 ). Substance abuse prevalence and comorbidity 
with other psychiatric disorders among adolescents with 
severe emotional disturbances. Journal of the American 
Academy of Child and Adolescent Psychiatry, 30, 
575-583. 

Greenbaum, S. D. (1998). The role of ethnography in creating 
linkages with communities: identifying and assessing 
neighborhoods' needs and strengths. In M. Hernandez & 
M. R. Isaacs (Eds.), Promoting cultural competence in 
children's mental health services (pp. 119-132). 
Baltimore: Paul H. Brookes. 

Greenhill, L. (1998a). Attention-deficit/hyperactivity disorder. 
In B. T. Walsh (Ed.), Child psychopharmacology (pp. 
91-109). Washington, DC: American Psychiatric 
Association Press. 



203 



Mental Health: A Report of the Surgeon General 



Greenhill, L. (1998b). Childhood attention deficit hyperactivity 
disorder: Pharmacological treatments. In P. E. Nathan & 
J. Gorman (Eds.), Treatments that work (pp. 42-64). 
Philadelphia: W. B. Saunders. 

Greenhill, L., Abikoff, H. B., Arnold, L. E., Cantwell, D. P., 
Conners, C. K., Elliott, G., Hechtman, L., Hinshaw, S. P., 
Hoza, B., Jensen, P. S., March, J. S., Newcom, J., 
Pelham, W. E., Severe, J. B., Swanson, J. M., Vitiello, B., 
& Wells, K. ( 1 996). Medication treatment strategies in the 
MTA Study: Relevance to clinicians and researchers. 
Journal of the American Academy of Child and 
Adolescent Psychiatry, 35, 1 304- 1313. 

Greenhill, L., Abikoff, H., Arnold, L., Cantwell, D., Conners, 
C. K., Cooper, T., Crowley, K., Elliot, G., Davies, M., 
Halperin, J., Hechtman, L., Hinshaw, S., Jensen, P., 
Klein, R., Lemer, M., March, J., MacBumett, K., Pelham, 
W., Severe, J., Sharma, V., Swanson, J., Vallano, G., 
Vitiello, B., Wigal, T., & Zametkin, A. (1998). 
Psychopharmacological treatment manual, NIMH 
multimodal treatment study of children with attention 
deficit hyperactivity disorder (MTA Study). New York: 
Psychopharmacology Subcommittee of the MTA Steering 
Committee. 

Grizenko, N. (1997). Outcome of multimodal day treatment 
for children with severe behavior problems: A five-year 
follow-up. Journal of the American Academy of Child 
and Adolescent Psychiatry, 36, 989-997. 

Grizenko, N., Papineau, D., & Sayegh, L. (1993). 
Effectiveness of a multimodal day treatment program for 
children with disruptive behavior problems. Journal of the 
American Academy of Child and Adolescent Psychiatry, 
32, 127-134. 

Groholt, B., Ekeberg, O., Wichstrom, L., & Haldorsen, T. 
(1997). Youth suicide in Norway, 1990-1992: A 
comparison between children and adolescents completing 
suicide and age- and gender-matched controls. Suicide 
and Life-Threatening Behavior, 27, 250-263. 

Grossman, P. B., & Hughes, J. N. (1992). Self-control 
interventions with internalizing disorders: A review and 
analysis. School Psychology Review, 21, 229-245. 

Guiterrez-Mayka, M., & Contreras-Neira, R. (1998). A 
culturally receptive approach to community participation 
in system reform. In M. Hernandez & M. R. Isaacs (Eds.), 
Promoting cultural competence in children's mental 
health services (pp. 133-148). Baltimore: Paul H. 
Brookes. 

Halperin, J. M., Newcom, J. H., Matier, K., Sharma, V., 
McKay, K. E., & Schwartz, S. (1993). Discriminant 
validity of attention-deficit hyperactivity disorder. Journal 
of the American Academy of Child and Adolescent 
Psychiatry, 32, 1038-1043. 

Hammen, C. (1988). Self-cognitions, stressful events, and the 
prediction of depression in children of depressed mothers. 
Journal of Abnormal Child Psychology, 16, 347-360. 



Hammen, C, Burge, D., Bumey, E., & Adrian, C. (1990). 
Longitudinal study of diagnoses in children of women 
with unipolar and bipolar affective disorder. Archives of 
General Psychiatry, 47, 1 1 12-1 1 17. 

Hamner, K. M., Lambert, E. W., & Bickman, L. (1997). 
Children's mental health in a continuum of care: Clinical 
outcomes at 18 months for the Fort Bragg demonstration. 
Journal of Mental Health Administration, 24, 465^71. 

Harrington, R. (1994). Affective disorders. In M. Conduct, E. 
Taylor, & L. Hersov (Eds.), Child and adolescent 
psychiatry: Modem approaches (3rd ed., pp. 330-350). 
Oxford: Blackwell Scientific Publications. 

Harrington, R., Fudge, H., Rutter, M., Pickles, A., & Hill, J. 
(1990). Adult outcomes of childhood and adolescent 
depression. I. Psychiatric status. Archives of General 
Psychiatry, 47, 465^73. 

Harrington, R., Kerfoot, M., Dyer, E., McNiven, F., Gill, J., 
Harrington, V., Woodham, A., & Byford, S. (1998). 
Randomized trial of a home-based family intervention for 
children who have deliberately poisoned themselves. 
Journal of the American Academy of Child and 
Adolescent Psychiatry, 37, 512-518. 

Hathaway, S. R., & McKinley, J. C. (1989). Minnesota 
Multiphasic Personality Inventory-II. Minneapolis, MN: 
University of Minnesota. 

Hawkins, R. P., Almeida, C, & Samet, M. (1989). 
Comparative evaluation of foster-family-based treatment 
and five other placement choices: A preliminary report. In 
A. Algarin, R. Friedman, A. Duchnowski, K. Kutash, S. 
Silver, & M. Johnson (Eds.), Children's mental health 
services and policy: Building a research base (pp. 
98-1 19). Tampa, FL: Research and Training Center for 
Children's Mental Health. 

Hay, D. F., Zahn-Waxler, C, Cummings, E. M., & lannotti, R. 
J. (1992). Young children's views about conflict with 
peers: A comparison of the daughters and sons of 
depressed and well women. Journal of Child Psychology 
and Psychiatry, 33, 669-683. 

Hazehigg, M. D., Cooper, H. M., & Borduin, C. M. (1987). 
Evaluating the effectiveness of family therapies: An 
integrative review and analysis. Psychological Bulletin, 
101, 428^42. 

Hechtman, L. (1985). Adolescent outcome of hyperactive 
children treated with stimulants in childhood: A review. 
Psychopharmacology Bulletin, 21, 178-191. 

Hechtman, L. (1993). Aims and methodological problems in 
multimodal treatment studies. Canadian Journal of 
Psychiatry, 38, 458^64. 

Heflinger, C. A., & Bickman, L. B. (1996). Family 
empowerment: a conceptual model for promoting parent- 
professional partnership. In C. A. Heflinger & C. Nixon 
(Eds.), Families and mental health services for children 
and adolescents (pp. 92-1 16). Newbury Park: Sage. 



204 



Children and Mental Health 



Heflinger, C. A., & Northrup, D. (1997). Interim report of the 
implementation study of the transition to managed mental 
health services at Fort Bragg, North Carolina. Nashville, 
TN: Vanderbilt Institute for Public Policy Studies, Center 
for Mental Health Policy. 

Hendren, R., & Mullen, D. (1997). Conduct disorder in 
childhood. In J. M. Weiner (Ed.), Textbook of child and 
adolescent psychiatry (2nd ed., pp. 427^440). 
Washington, DC: American Academy of Child and 
Adolescent Psychiatry, American Psychiatric Press. 

Henggeler, S. W., Melton, G. B., & Smith, L. A. (1992). 
Family preservation using multisystemic therapy: An 
effective alternative to incarcerating serious juvenile 
offenders. Journal of Consulting and Clinical 
Psychology, 60,953-961. 

Henggeler, S. W., Rodick, J. D., Borduin, C. M., Hanson, C. 
L., Watson, S. M., & Urey, J. R. (1986). Multisystemic 
treatment of juvenile offenders: Effects on adolescent 
behavior and family interaction. Developmental 
Psychology, 22, 132-141. 

Henggeler, S. W., Schoenwald, S. K., Borduin, C. M., 
Rowland, M. D., & Cunningham, P. B. (1998). 
Multisystemic treatment of antisocial behavior in children 
and adolescents. New York: Guilford Press. 

Hernandez, M., & Isaacs, M. R. (Eds.). (1998). Promoting 
cultural competence in children 's mental health services. 
Baltimore: Paul H. Brookes. 

Hernandez, M., Isaacs, M. R., Nesman, T., & Bums, D. 
(1998). Perspectives on culturally competent systems of 
care. In M. Hernandez & Isaacs, M. R. (Eds.), Promoting 
cultural competence in children 's mental health services 
(pp. 1-25). Baltimore: Paul H. Brookes. 

Herzog, D. B., Dorer, D. J., Keel, P. K., Selwyn, S. E., 
Ekeblad, E. R., Flores, A. T., Greenwood, D. N., Burwell, 
R. A., & Keller, M. B. (1999). Recovery and relapse in 
anorexia and bulimia nervosa: A 7.5-year follow- up 
study. Journal of the American Academy of Child and 
Adolescent Psychiatry, 38, 829-837. 

Herzog, D. B., Nussbaum, K. M., & Marmor, A. K., (1996). 
Comorbidity and outcome in eating disorders. Psychiatric 
Clinics of North America, 19, 843-859. 

Hinckley, E. C, & EUis, W. F. (1985). An effective 
alternative to residential placement: Home-based services. 
Journal of Clinical Child Psychology, 14, 209-213. 

Hinshaw, S. P., & Erhardt, D. (1991). Attention-deficit 
hyperactivity disorder. In P. Kendall (Ed.), Child and 
adolescent therapy: Cognitive-behavioral procedures (pp. 
98-128). New York: Guilford Press. 

Hoagwood, K. (1997). Interpreting nullity. The Fort Bragg 
experiment — a comparative success or failure? American 
Psychologist, 52, 546-550. 

Hoagwood, K., & Erwin, H. D. (1997). Effectiveness of 
school-based mental health services for children: A 10- 
year research review. Journal of Child and Family 
Studies, 6, 435^54. 



Hoagwood, K., Jensen, P. S., Petti, T., & Bums, B. J. (1996). 
Outcomes of mental health care for children and 
adolescents: I. A comprehensive conceptual model. 
Journal of the American Academy of Child and 
Adolescent Psychiatry, 35, 1055-1063. 

Hoagwood, K., Kelleher, K., Feil, M., & Comer, D. (1998, 
November 16). NIH Consensus Development Conference, 
Bethesda, MD. 

Hoberman, H. M. (1992). Ethnic and minority status and 
adolescent mental health services utilization. Journal of 
Mental Health Administration, 19, 246-267. 

Holden, E. W., Brannan, A. M., English, M. E., Friedman, R. 
M., Hemandez, M., & Osher, T. (1999, Febmary). 
Update on the national evaluation of the Comprehensive 
Community Mental Health Services for Children and 
Their Families' Program: Outcomes of the national 
evaluation. Paper presented at the 12th annual 
Conference on the System of Care for Children's Mental 
Health Tampa, Florida. 

HolUs, C. (1996). Depression, family environment, and 
adolescent suicidal behavior. Journal of the American 
Academy of Child and Adolescent Psychiatry, 35, 
622-630. 

Hops, H., Lewinsohn, P. M., Andrews, J. A., & Roberts, R. E. 
(1990). Psychosocial correlates of depressive 
symptomatology among high school students. Journal of 
Clinical and Child Psychology, 19, 21 1-220. 

Horacek, H. J., Ramey, C. T., Campbell, F. A., Hoffmann, K. 
P., & Fletcher, R. H. (1987). Predicting school failure and 
assessing early intervention with high-risk children. 
Journal of the American Academy of Child and 
Adolescent Psychiatry, 26, 758-763. 

Hom, W. F., lalongo, N., Greenberg, G., Packard, T., & 
Smith-Winberry, C. (1990). Additive effects of behavioral 
parent training and self-control therapy with ADHD 
children. Journal of Clinical Child Psychology, 19, 
98-110. 

Hom, W. F., lalongo, N. S., Pascoe, J. M., Greenberg, G., 
Packard, T., Lopez, M., Wagner, A., & Puttier, L. (1991). 
Additive effects of psychostimulants, parent training, and 
self-control therapy with ADHD children. Journal of the 
American Academy of Child and Adolescent Psychiatry, 
30, 233-240. 

Hom, W. F., lalongo, N., Popovich S., & Peradotto, D. (1987). 
Behavioral parent training and cognitive behavioral self- 
control therapy with ADD-H children: Comparative and 
combined effects. Journal of Clinical Child Psychology, 
16, 57-68. 

Hoyert, D. L., Kochanek, K. D., & Murphy, S. L. (1999). 
Deaths: Final data for 1997. National Vital Statistics 
Reports, 47(9). Hyattsville, MD: National Center for 
Health Statistics. 



205 



Mental Health: A Report of the Surgeon General 



Hunt, R. D. (1987). Treatment effects of oral and transdermal 
clonidine in relation to methylphenidate: An open pilot 
study in ADD-H. Psychophartnacology Bulletin, 23, 
111-114. 

Hunt, R. D., Amsten, A. F., & Asbell, M. D. ( 1995). An open 
trial of guanfacine in the treatment of attention-deficit 
hyperactivity disorder. Journal of the American Academy 
of Child and Adolescent Psychiatry, 34, 50-54. 

Hunt, R. D., Capper, L., & O'Connell, P. (1990). Clonidine in 
child and adolescent psychiatry. Journal of Child and 
Adolescent Psychopharmacology, 1, 87-102. 

Illback, R. J., Nelson, C. M., & Sanders, D. (1998). 
Community-based services in Kentucky: Description and 
5-year evaluation of Kenmcky IMPACT. In M. H. 
Epstein, K. Kutash, & A. Duchnoski (Eds.), Outcomes for 
children and youth with behavioral and emotional 
disorders and their families (pp. 141-172). Austin, TX: 
Pro-Ed. 

Infant Health and Development Program. (1990). Enhancing 
the outcomes of low-birth-weight, premature infants. A 
multisite, randomized trial. The Infant Health and 
Development Program. Journal of the American Medical 
Association, 263, 3035-3042. 

Inhelder, B., & Piaget, J. (1958). The growth of logical 
thinking from childhood to adolescence: An essay on the 
construction of formal operational structures. New York: 
Basic Books. 

Isaacs-Shockley, M., Cross, T., Bazron, B. J., Dennis, K., & 
Benjamin, M. (1996). Framework for a culturally 
competent system of care. In B. A. Stroul (Ed.), 
Children's mental health: Creating systems of care in a 
changing society (pp. 23^0). Baltimore: Paul H. 
Brookes. 

Jacobi, C, Dahme, B., & Rustenbach, S. (1997). [Comparison 
of controlled psycho- and pharmacotherapy studies in 
bulimia and anorexia nervosa.]. Psychotherapie, 
Psychosomatik, Medizinische Psychologic, 47, 346-364. 

Jameson, P. B., Gelfand, D. M., Kulcsar, E., & Teti, D. M. 
(1997). Mother-toddler interaction patterns associated 
with maternal depression. Developmental 
Psychopathology, 9, 537-550. 

Jenkins, E., & Bell, C. (1997). Exposure and response to 
community violence among children and adolescents. In 
Osofsky, J. (Ed.). Children in a violent society (pp. 9-31). 
Guilford Press: New York. 

Jensen, J. A., McNamara, J. R., & Gustafson, K. E. (1991). 
Parents' and clinicians' attimdes toward the risks and 
benefits of child psychotherapy: A smdy of informed- 
consent content. Professional Psychology, Research and 
Practice, 22, 161-170. 

Jensen, P. S. (1998). Developmental psycho-pathology courts 
developmental neurobiology: Current issues and future 
challenges. Seminars in Clinical Neuropsychiatry, 3, 
333-337. 



Jensen, P. S., Bhatara, V. S., Vitiello, B., Hoagwood, K., Fell, 

M., & Burke, L. B. (1999). Psychoactive medication 

prescribing practices for U.S. children: Gaps between 

research and clinical practice. Journal of the American 

Academy of Child and Adolescent Psychiatry, 38, 

557-565. 
Jensen, P. S., & Hoagwood, K. (1997). The book of names: 

DSM-FV in context. Developmental Psychopathology, 9, 

231-249. 
Jimerson, D. C, Herzog, D. B., & Brotman, A. W. (1993). 

Pharmacologic approaches in the treatment of eating 

disorders. Harx'ard Review of Psychiatry, 1, 82-93. 
Johnson, D. L., & Breckenridge, J. N. (1982). The Houston 

Parent-Child Development Center and the primary 

prevention of behavior problems in young children. 

American Journal of Community Psychology, 10, 

305-316. 
Johnston, L. D., O'Malley, P. M., & Backman, J. G. (1996). 

National survey results on drug use from the Monitoring 

the Future study, 1975-1995. Vol. 1: Secondary school 

students. (NIH Pub. No. 97-4139). Rockville, MD: 

National Institute on Drug Abuse. 
Johnston, C, Pelham, W. E., Hoza, J., & Sturges, J. (1988). 

Psychostimulant rebound in attention deficit disordered 

boys. Journal of the American Academy of Child and 

Adolescent Psychiatry, 27, 806-810. 
Joshi, P. K., & Rosenberg, L. A. (1997). Children's behavioral 

response to residential treatment. Journal of Clinical 

Psychology, 53, 567-573. 
Kafantaris, V., Campbell, M., Padron-Gayol, M. V., Small, A. 

M., Locascio, J. J., & Rosenberg, C. R. (1992). 

Carbamazepine in hospitalized aggressive conduct 

disorder children: An open pilot study. 

Psychopharmacology Bulletin, 28, 193-199. 
Kagan, J. (1984). The nature of the child. New York: Basic 

Books. 
Kagan, J. (1989). Unstable ideas: Temperament, cognition 

and self. Cambridge, MA: Harvard University Press. 
Kagan, J. (1994). Galen 's prophecy. New York: Basic Books. 
Kagan, J. (1995). On attachment. Harvard Review of 

Psychiatry, 3, 104-106. 
Kagan, J., & Gall, S. B. (Eds.). (1998). The Gale encyclopedia 

of childhood and adolescence. Detroit: Gale. 
Kagan, J., Reznick, J. S., & Snidman, N. (1988). Biological 

bases of childhood shyness. Science, 240, 167-171. 
Kagan, J., Snidman, N.. & Arcus, D. (1998). Childhood 

derivatives of high and low reactivity in infancy. Child 

Development, 69, 1483-1493. 
Kandel, D. B., & Davies, M. (1982). Epidemiology of 

depressive mood in adolescents: An empirical study. 

Archives of General Psychiatry, 39, 1205-1212. 



206 



Children and Mental Health 



Karoly, L. A., Greenwood, P. W., Everingham, S. S., Hoube, 
J., Kilbum, M. R., Rydell, C. P., Sanders, M., & Chiesa, 
J. (1998). Investing in our children: What we know and 
don 't know about the costs and benefits of childhood 
interventions. Santa Monica, CA: Rand Corporation. 

Kaslow, N. J., & Thompson, M. P. (1998). Applying the 
criteria for empirically supported treatments to studies of 
psychosocial interventions for child and adolescent 
depression. Journal of Clinical Child Psychology, 27, 
146-155. 

Kaufman, J. (1991). Depressive disorders in maltreated 
children. Journal of the American Academy of Child and 
Adolescent Psychiatry, 30, 257-265. 

Kaye, W., Strober, M., Stein, D., & Gendall, K. (1999). New 
directions in treatment research of anorexia and bulimia 
nervosa. Biological Psychiatry, 45, 1285-1292. 

Kazdin, A. E., Esveldt-Dawson, K., French, N. H., & Unis, A. 
S. (1987a). Effects of parent management training and 
problem-solving skills training combined in the treatment 
of antisocial child behavior. Journal of the American 
Academy of Child and Adolescent Psychiatry, 26, 
416-424. 

Kazdin, A. E. (1996). Developing effective treatments for 
children and adolescents. In E. D. Hibbs & P. S. Jensen 
(Eds.), Psychosocial treatments for child and adolescent 
disorders: Empirically based strategies for clinical 
practice (pp. 9-18). Washington, DC: American 
Psychological Association. 

Kazdin, A. E., Esveldt-Dawson, K., French, N. H., & Unis, A. 
S. (1987b). Problem-solving skills training and 
relationship therapy in the treatment of antisocial child 
behavior. Journal of Consulting and Clinical Psychology, 
55, 76-85. 

Kazdin, A. E., Holland, L., & Crowley, M. (1997). Family 
experience of barriers to treatment and premature 
termination from child therapy. Journal of Consulting and 
Clinical Psychology, 65, 453^63. 

Kazdin, A. E., Moser, J., Colbus, D., & Bell, R. (1985). 
Depressive symptoms among physically abused and 
psychiatrically disturbed children. Journal of Abnonnal 
Psychology, 94, 298-307. 

Kazdin, A. E., Siegel, T. C, & Bass, D. (1990). Drawing on 
clinical practice to inform research on child and 
adolescent psychotherapy: Survey to practitioners. 
Professional Psychology: Research and Practice, 21, 
189-198. 

Kearney, C. A., & Silverman, W. K. (1998). A critical review 
of pharmacotherapy for youth with anxiety disorders: 
Things are not as they seem. Journal of Anxiety 
Disorders, 12, 83-102. 

Kellam, S. G.. & Anthony, J. C. (1998). Targeting early 
antecedents to prevent tobacco smoking: Findings from an 
epidemiologically based randomized field trial. American 
Journal of Public Health, 88, 1490-1495. 



Kemph, J. P., DeVane, C. L., Levin, G. M., Jarecke, R., & 
Miller, R. L. (1993). Treatment of aggressive children 
with clonidine: Results of an open pilot study. Journal of 
the American Academy of Child and Adolescent 
Psychiatry, 32, 511-5U. 

Kendall, P. C. (1994). Treating anxiety disorders in children: 
Results of a randomized clinical trial. Journal of 
Consulting and Clinical Psychology, 62, 100-1 10. 

Kendall, P. C, Chansky, T. E., Kane, M. T., Kim, R., 
Kortlander, E., Ronan, K. R., Sessa, F. M., & Siqueland, 
L. (1992). Anxiety disorders in youth: Cognitive- 
behavioral interventions. Needham Heights, MA: AUyn 
& Bacon. 

Kendall, P. C, Flannery-Schroeder, E., Panichelli-Mindel, S. 
M., Southam-Gerow, M., Henin, A., & Warman, M. 
(1997). Therapy for youths with anxiety disorders: A 
second randomized clinical trial. Journal of Consulting 
and Clinical Psychology, 65, 366-380. 

Kendler, K. S. (1995). Genetic epidemiology in psychiatry. 
Taking both genes and environment seriously. Archives of 
General Psychiatry, 52, 895-899. 

Kemberg, P. F. (1994). Psychological interventions for the 
suicidal adolescent. American Journal of Psychotherapy, 
48, 52-63. 

Kessler, R. C, McGonagle, K. A., Zhao, S., Nelson, C. B., 
Hughes, M., Eshleman, S., Wittchen, H. U., & Kendler, 
K. S. (1994). Lifetime and 12-month prevalence of DSM- 
ni-R psychiatric disorders in the United States. Results 
from the National Comorbidity Survey. Archives of 
General Psychiatry, 51, 8-19. 

Kessler, R. C, Nelson, C. B., McKonagle, K. A., Edlund, M. 
J., Frank, R. G., & Leaf, P. J. (1996). The epidemiology 
of co-occurring addictive and mental disorders: 
Implications for prevention and service utilization. 
American Journal of Orthopsychiatry, 66, 17-31. 

Kessler, R. C, & Walters, E. E. (1998). Epidemiology of 
DSM-rH-R major depression and minor depression 
among adolescents and young adults in the National 
Comorbidity Survey. Depression and Anxiety, 7, 3-14. 

Kienhorst, I. C, De Wilde, E. J., Diekstra, R. F., & Wolters, 
W. H. (1995). Adolescents' image of their suicide 
attempt. Journal of the American Academy of Child and 
Adolescent Psychiatry, 34, 623-628. 

Kirigin, K. A., Braukmann, C. J., Atwater, J. D., & Wolf, M. 
M. (1982). An evaluation of Teaching-Family 
(Achievement Place) group homes for juvenile offenders. 
Journal of Applied Behavior Analysis, 15, 1-16. 

Kiser, L. J., Pruitt, D. B., McColgan, E. B., & Ackerman, B. 
J. (1986). A survey of child and adolescent day-treatment 
programs: Estabhshing definitions and standards. 
International Journal of Partial Hospitalization, 3, 
247-59. 



207 



Mental Health: A Report of the Surgeon General 



Klein, D. N., Lewinsohn, P. M., & Seeley, J. R. (1997a). 
Psychosocial characteristics of adolescents with a past 
history of dysthymic disorder: Comparison with 
adolescents with past histories of major depressive and 
non-affective disorders, and never mentally ill controls. 
Journal of Affective Disorders, 42, 127-135. 

Klein, R. (1991, May). CME syllabus and proceedings 
summary, 144th annual meeting of the American 
Psychiatric Association, New Orleans, LA. 

Klein, R. G., Abikoff, H., Klass, E., Ganeles, D., Seese, L. M., 
& Pollack, S. (1997b). Clinical efficacy of 
methylphenidate in conduct disorder with and without 
attention deficit hyperactivity disorder. Archives of 
General Psychiatry, 54, 1073-1080. 

Klein, R. G., Koplewicz, H. S., & Kanner, A. (1992). 
Imipramine treatment of children with separation anxiety 
disorder. Journal of the American Academy of Child and 
Adolescent Psychiatry, 31, 21-28. 

Klein, R. G., & Mannuzza, S. (1988). Hyperactive boys almost 
grown up. in. Methylphenidate effects on ultimate height. 
Archives of General Psychiatry, 45, 1131-1134. 

Knitzer J. (1982). Unclaimed children: The failure of public 
responsibility to children and adolescents in need of 
mental health services. Washington, DC: Children's 
Defense Fund. 

Knitzer, J., Steinberg, Z., & Heisch, B. (1993). At the 
schoolhouse door: An examination of programs and 
policies for children with behavioral and emotional 
problems. New York: Bank Street College of Education. 

Koluchova, J. (1972). Severe deprivation in twins: A case 
study. Journal of Child Psychology and Psychiatry, 13, 
107-114. 

Kolvin, I., Barrett, M. L., Bhate, S. R., Bemey, T. P., 
Famuyiwa, O. O., Fundudis, T., & Tyrer, S. (1991). The 
Newcastle Child Depression Project. Diagnosis and 
classification of depression. British Journal of Psychiatry. 
Supplement, 11, 9-21. 

Koren, P. E., Paulson, R., Kinney, R., Yatchmonoff, D., 
Gordon, L., & DeChillo, N. (1997). Service coordination 
in children's mental health: An empirical study from the 
caregivers perspective. Journal of Emotional and 
Behavioral Disorders, 5, 62-172. 

Koroloff, N. M., Elliot, D. J., Koren, P. E., & Friesen, B. J. 
(1991). Support groups for parents and children with 
emotional disorders: A comparison of members and 
nonmembers. Community Mental Health Journal, 27, 
265-279. 

Koroloff, N. M., Elliot, D. J., Koren, P. E., & Friesen, B. J. 
( 1 996a) . Linking low-income families to children' s mental 
health services: An outcome study. Journal of Emotional 
and Behavioral Disorders, 4, 2-11. 

Koroloff, N. M., & Friesen, B. J. (1991). Support groups for 
parents of children with emotional disorders: A 
comparison of members and non-members. Community 
Mental Health Journal, 27, 265-279. 



Koroloff, N. M., Friesen, B. J., Resilly, L., & Rinkin, J. 
(1996b). The role of family members in systems of care. 
In B. Stroul (Ed.), Children's mental health: Creating 
systems of care in a changing society (pp. 409^26). 
Baltimore: Paul H. Brookes. 

Kovacs, M. (1985). The children's depression inventory. 
Psychopharmacology Bulletin, 21, 995-998. 

Kovacs, M., Obrosky, D. S., Gastonis, C, & Richards, C. 
(1997a). First-episode major depressive and dysthymic 
disorder in childhood: Clinical and sociodemographic 
factors in recovery. Journal of American Academy of 
Child and Adolescent Psychiatry, 36, 111-1%A. 

Kovacs, M., Akiskal, H. S., Gatsonis, C, & Parrone, P. L. 
(1994). Childhood-onset dysthymic disorder. Clinical 
features and prospective naturalistic outcome. Archives of 
General Psychiatry, 51, 365-374. 

Kovacs, M., Devlin, B., Pollock, M., Richards, C, & Mukerji, 
P. (1997b). A controlled family history study of 
childhood-onset depressive disorder. Archives of General 
Psychiatry, 54, 613-623. 

Kraemer, H. C, Kazdin, A. E., Offord, D. R., Kessler, R. C, 
Jensen, P. S., & Kupfer, D. J. (1997). Coming to terms 
with the terms of nsk.. Archives of General Psychiatry, 54, 
337-343. 

Kretzman, J. P., & McKnight, J. L. (1993). Building 
communities from the inside out: A path toward finding 
and mobilizing a community's assets. Evanston, IL: 
Northwestern University, Center for Urban Affairs and 
Policy Research, Neighborhood Innovations Network. 

Kulik, J. A., Stein, K. B., & Sarbin, T. R. (1968). Dimensions 
and patterns of adolescent behavior. Journal of 
Consulting and Clinical Psychology, 48, 1 134-1 144. 

Kumar, R. C. (1997). "Anybody's child": Severe disorders of 
mother-to-infant bonding. British Journal of Psychiatry, 
171, 175-181. 

Kutash, K., & Rivera, V. R. (1996). What works in children 's 
mental health services: Uncovering answers to critical 
questions. Baltimore: Paul H. Brookes. 

Kutcher, S. (1998). Affective disorders in children and 
adolescents: A critical chnically relevant review. In B. T. 
Walsh (Ed.), Child psychopharmacology (pp. 91-109). 
Washington, DC: American Psychiatric Association 
Press. 

Lamb, M. E. (1975). The sociability of two-year-olds with 
their mothers and fathers. Child Psychiatry and Human 
Development, 5, 182-183. 

Lambert, E. W., & Guthrie, P. R. (1996). Clinical outcomes of 
a children's mental health managed care demonstration. 
Journal of Mental Health Administration, 23, 51-68. 

Landrum, T. J., Singh, N. N., Nemil, M. S., EUis, C. R., & 
Best, A. M. (1995). Characteristics of children and 
adolescents with serious emotional disturbance in systems 
of care. Part II: Community based services. Journal of 
Emotional and Behavioral Disorders, 3, 141-149. 



208 



Children and Mental Health 



Langmeyer, D. L. (1997). Cost control and the Fort Bragg 
project: Does a continuum of care have to cost more? In 
S. A. Pires (Ed.), Lessons learned from the Fort Bragg 
Demonstration (pp. 91-100). Tampa, FL: University of 
South Florida, Research and Training Center for 
Children's Mental Health. 

Laufer, M. W. (1971). Long-term management and some 
follow-up findings on the use of drugs with minimum 
cerebral syndromes. Journal of Learning Disabilities, 4, 
519-522. 

Laufer, M., & Denhoff, E. (1957). Hyperkinetic behavior 
syndrome in children. Journal ofPediatrics, 50, 463^74. 

Lavigne, J. V., Gibbons, R. D., Christoffel, K. K., Arend, R., 
Rosenbaum, D., Binns, H., Dawson, N., Sobel, H., & 
Isaacs, C. (1996). Prevalence rates and correlates of 
psychiatric disorders among preschool children. Journal 
of the American Academy of Child and Adolescent 
Psychiatry, 35, 204-214. 

Leaf, P. J., Alegria, M., Cohen, P., Goodman, S. H., Horwitz, 
S. M., Hoven, C. W., Narrow, W. E., Vaden-Kieman, M., 
& Regier, D. A. (1996). Mental health service use in the 
community and schools: Results from the four-community 
MECA Study. Methods for the Epidemiology of Child 
and Adolescent Mental Disorders Study. Journal of the 
American Academy of Child and Adolescent Psychiatry, 
35, 889-897. 

Leckman, J. F., Peterson, B. S., Pauls, D. L., & Cohen, D. J. 
(1997). Tic disorders. Psychiatric Clinics of North 
America, 20, 839-861. 

Lee, M. Y. (1996). A construct! vist approach to the help- 
seeking process of clients: A response to cultural 
diversity. Clinical Social Work Journal, 24, 187-202. 

Lee, V. E., Brooks-Gunn, J., Schnur, E., & Liaw, F. R. (1990). 
Are Head Start effects sustained? A longitudinal follow- 
up comparison of disadvantaged children attending Head 
Start, no preschool, and other preschool programs. Child 
Development, 61, 495-507. 

Lenane, M. C, Swedo, S. E., Leonard, H., Pauls, D. L., 
Sceery, W., & Rapoport, J. L. (1990). Psychiatric 
disorders in first degree relatives of children and 
adolescents with obsessive-compulsive disorder. Journal 
of the American Academy of Child and Adolescent 
Psychiatry, 29, 407^12. 

Leonard, H. L., Rapoport, J. L., & Swedo, S. E. (1997). 
Obsessive-compulsive disorder. In J. M. Weiner (Ed.), 
Textbook of child and adolescent psychiatry (2nd ed., pp. 
481-490). Washington, DC: American Academy of Child 
and Adolescent Psychiatry, American Psychiatric Press. 

Letizia, C, Kapik, B., & Flanders, W. D. (1996). Suicidal risk 
during controlled clinical investigations of fluvoxamine. 
Journal of Clinical Psychiatry, 57, 415^21. 

Lewinsohn, P. M., Clarke, G. N., Hops, H., & Andrews, J. 
(1990). Cognitive-behavioral treatment for depressed 
adolescents. Behavior Therapy, 21, 385-401. 



Lewinsohn, P. M., Clarke, G. N., Rhode, P., Hops, H., & 
Seely, J. (1996). A course in coping: A cognitive- 
behavioral approach to the treatment of adolescent 
depression. In D. Hibbs & P. S. Jensen (Eds.), 
Psychosocial treatments for child and adolescent 
disorders: Empirically based strategies for clinical 
practice (pp. 109-135). Washington, DC: American 
Psychological Association. 

Lewinsohn, P. M., Clarke, G. N., Seeley, J. R., & Rohde, P. 
(1994a). Major depression in community adolescents: 
Age at onset, episode duration, and time to recurrence. 
Journal of the American Academy of Child and 
Adolescent Psychiatry, 33, 809-818. 

Lewinsohn, P. M., Roberts, R. E., Seeley, J. R., Rohde, P., 
Gotlib, I. H., & Hops, H. (1994b). Adolescent 
psychopathology: E. Psychosocial risk factors for 
depression. Journal of Abnormal Psychology, 103, 
302-315. 

Lewinsohn, P. M., Steinmetz, J. L., Larson, D. W., & 
Franklin, J. (1981). Depression-related cognitions: 
Antecedent or consequence? Journal of Abnotmal 
Psychology, 90, 213-219. 

Lewis, W. W. (1988). The role of ecological variables in 
residential treatment. Behavioral Disorders, 13, 98-107. 

Linehan, M. M., Heard, H. L., & Armstrong, H. E. (1993). 
Naturalistic follow-up of a behavioral treatment for 
chronically parasuicidal borderline patients. Archives of 
General Psychiatry, 50, 911-91 A. 

Link, B. G., Dohrenwend, B. P., & Skodol, A. E. (1986). 
Socioeconomic status and schizophrenia: Noisome 
occupational characteristics as a risk factor. American 
Sociological Review, 51, 242-258. 

Linn, J. G., & McGranahan, D. A. (1980). Personal 
disruptions, social integration, subjective well-being, and 
predisposition toward the use of counseling services. 
American Journal of Community Psychology, 8, 87-100. 

Locascio, J. J., Malone, R. P., Small, A. M., Kafantaris, V., 
Ernst, M., Lynch, N. S., Overall, J. E., & Campbell, M. 
(1991). Factors related to haloperidol response and 
dyskinesias in autistic children. Psychopharmacology 
Bulletin, 27, 119-126. 

Lochman, J. E. (1992). Cognitive-behavioral intervention with 
aggressive boys: Three-year follow-up and preventive 
effects. Journal of Consulting and Clinical Psychology, 
60, A26-A32. 

Loeber, R., & Farrington, D. P. (Eds.). (1998). Serious and 
violent juvenile offenders: Risk factors and successful 
interventions. Thousand Oaks, CA: Sage. 

Loeber, R., & Stouthamer-Loeber, M. (1986). Family factors 
as coiTelates and predictors of juvenile conduct problems 
and delinquency. In M. Tonry & N. Morris (Eds.), Crime 
and justice (Vol. 7). Chicago: University of Chicago 
Press. 



209 



Mental Health: A Report of the Surgeon General 



Lonigan, C. J., Elbert, J. C, & Johnson, S. B. (1998). 
Empirically supported psychosocial interventions for 
children: An overview. Journal of Clinical Child 
Psychology, 27, 138-145. 

Lourie, I. S. (1997). Service delivery lessons from the Fort 
Bragg project. In S. A. Pires (Ed.), Lessons learned from 
the Fort Bragg Demonstration (pp. 23-56). Tampa, FL: 
University of South Florida, Research and Training 
Center for Children's Mental Health. 

Lourie, I. S., Howe, S. H., & Roebuck, L. L. (1996). 
Systematic approaches to mental health care in the 
private sector for children, adolescents, and the families. 
Washington, DC: Georgetown University Child 
Development Center, National Technical Assistance 
Center for Child Mental Health. 

Lovaas, O. I. (1987). Behavioral treatment and normal 
educational and intellectual functioning in young autistic 
children. Journal of Consulting and Clinical Psychology, 
55, 3-9. 

Luria, A. R. (1971). Towards the problem of the historical 
nature of psychological processes. International Journal 
of Psychology, 6, 259-272. 

Main, M., & Solomon, J. (1990). Procedures for identifying 
infants as disorganized/disoriented during the Ainsworth 
strange situation. In M. Greenberg, D. Cicchetti, & E. M. 
Cummings (Eds.), Attachment during preschool years 
(pp. 121-160). Chicago, IL: University of Chicago Press. 

Mann, J. J. (1998). The neurobiology of suicide. Nature 
Medicine, 4, 25-30. 

Mannuzza, S., Klein, R. G., Bessler, A., Malloy, P., & 
LaPadula,M. (1993). Adult outcome of hyperactive boys. 
Educational achievement, occupational rank, and 
psychiatric status. Archives of General Psychiatry, 50, 
565-576. 

Mannuzza, S., Klein, R. G., Bessler, A., Malloy, P., & 
LaPadula, M. (1998). Adult psychiatric status of 
hyperactive boys grown up. American Journal of 
Psychiatry, 155, 493-498. 

March, J. S., Frances, A., Carpenter, D., & Kahn, D. A. 
(1997). Treatment of obsessive-compulsive disorder. The 
Expert Consensus Panel for obsessive-compulsive 
disorder. Journal of Clinical Psychiatry, 58 , 2-72. 

Martin, S. L., Ramey, C. T., & Ramey, S. (1990). The 
prevention of intellectual impairment in children of 
impoverished families: Findings of a randomized trial of 
educational day care. American Journal of Public Health, 
80, 844-847. 

Mattes, J. A., & Gittelman, R. ( 1 98 1 ). Effects of artificial food 
colorings in children with hyperactive symptoms. A 
critical review and results of a controlled study. Archives 
of General Psychiatry, 38, 714-718. 



Maziade, M., Caperaa, P., Laplante, B., Boudreault, M., 
Thivierge, J., Cote, R., & Boutin, P. (1985). Value of 
difficult temperament among seven-year-olds in the 
general population for predicting psychiatric diagnosis at 
age 12. American Journal of Psychiatry, 142, 943-946. 

McCabe, K., Yeh, M., Hough, R., Landsverk, J., Hurlburt, M., 
Culver, S., & Reynolds, B. (1998). Racial/ethnic 
representation across five public sectors of care for 
youth. San Diego, CA: Center for Research on Child and 
Adolescent Mental Health Services. 

McCarton, C. M., Brooks-Gunn, J., Wallace, I. F., Bauer, C. 
R., Bennett, F. C, Bembaum, J. C, Broyles, R. S., Casey, 
P. H., McCormick, M. C, Scott, D. T., Tyson, J., 
Tonascia, J., & Meinert, C. L. (1997). Results at age 8 
years of early intervention for low-birth- weight premature 
infants. The Infant Health and Development Program. 
Journal of the American Medical Association, 277, 
126-132. 

McClellan, J., & Werry, J. (in press). Practice parameters for 
the assessment and treatment of children and adolescents 
with schizophrenia. Journal of the American Academy of 
Child and Adolescent Psychiatry. 

McCracken, J. T. (1992a). The epidemiology of child and 
adolescent mood disorders. In D. P. Cantwell & M. P. 
Lewis (Eds.), Child and adolescent psychiatric clinics of 
North America: Mood disorders. Philadelphia: W. B. 
Saunders. 

McCracken, J. T. (1992b). Etiologic aspects of child and 
adolescent mood disorders. In D. P. Cantwell & M. Lewis 
(Eds.), Child and adolescent psychiatric clinics of North 
America: Mood disorders. Philadelphia: W. B. Saunders. 

McDougle, C. J., Naylor, S. T., Cohen, D. J., Volkmar, F. R., 
Heninger, G. R., & Price, L. H. (1996). A double-blind, 
placebo-controlled study of fluvoxamine in adults with 
autistic disorder. Archives of General Psychiatry, 53, 
1001-1008. 

McEachin, J. J., Smith, T., & Lovaas, O. I. (1993). Outcome 
in adolescence of autistic children receiving early 
intensive behavioral treatment. American Journal of 
Mental Retardation, 97, 359-372. 

McGee, R., Feehan, M., Wilhams, S., Partridge, F., Silva, P. 
A., & Kelly, J. (1990). DSM-HI disorders in a large 
sample of adolescents. Journal of the American Academy 
of Child and Adolescent Psychiatry, 29, 611-619. 

McKay, M. M., Nudelman, R., McCadam, K., & Gonzales, J. 
(1996). Evaluating a social work engagement approach to 
involving inner-city children and their families in mental 
health care. Research on Social Work Practice, 6, 
A61-A12. 

McMiller, W. P., & Weisz, J. R. (1996). Help-seeking 
preceding mental health clinic intake among African- 
American, Latino, and Caucasian youths. Journal of the 
American Academy of Child and Adolescent Psychiatry, 
35, 1086-1094. 



210 



Children and Mental Health 



Merikangas, K. R., Prusoff, B. A., & Weissman, M. M. 
(1988). Parental concordance for affective disorders: 
Psychopathology in offspring. Journal of Affective 
Disorders, 15, 279-290. 

Merrick, E. (1998). Treatment of major depression before and 
after implementation of a behavioral health carve-out 
plan. Psychiatric Services, 49, 1563-1567. 

Milich, R., & Pelham, W. E. (1986). Effects of sugar ingestion 
on the classroom and playground behavior of attention 
deficit disordered boys. Journal of Consulting and 
Clinical Psychology, 54, 714-718. 

Miller, H. L., Coombs, D. W., Leeper, J. D., & Barton, S. N. 
(1984). An analysis of the effects of suicide prevention 
facilities on suicide rates in the United States. American 
Journal of Public Health, 74, 340-343. 

Miller, K. E., King, C. A., Shain, B. N., & Naylor, M. W. 
(1992). Suicidal adolescents' perceptions of their family 
environment. Suicide and Life-Threatening Behavior, 22, 
226-239. 

Millon, T., Green, C. J., & Meagher, Jr., R. B. (1982). Millon 
Adolescent Personality Inventory. Minneapohs, MN: 
National Computer Systems. 

Mitchell, S. A. (1993). Aggression and the endangered self. 
Psychoanalytic Quarterly, 62, 351-352. 

Montgomery, S. A., & Montgomery, D. (1982). 
Pharmacological prevention of suicidal behavior. Journal 
of Affective Disorders, 4, 291-298. 

Morgan, A. E., Hynd, G. W., Riccio, C. A., & Hall, J. (1996). 
Validity of DSM-IV ADHD predominantly inattentive 
and combined types: Relationship to previous DSM 
diagnoses/subtype differences. Journal of the American 
Academy of Child and Adolescent Psychiatry, 35, 
325-333. 

Moscicki, E. K. (1995). Epidemiology of suicide. 
International Psychogeriatrics, 7, 137-148. 

Mrazek, P. (1998). Preventing mental health and substance 
abuse problems in managed health care settings. 
Alexandria, VA: National Mental Health Association. 

MTA Cooperative Group. (1998, October). A 14-month 
randomized clinical trial of treatment strategies for 
attention deficit hyperactivity disorder. Paper presented at 
the annual meeting of the American Academy of Child 
and Adolescent Psychiatry, Anaheim, CA. 

Mufson, L., Weissman, M. M., & Warner, V. (1992). 
Depression and anxiety in parents and children: A direct 
interview study. Journal of Anxiety Disorders, 6, 1-13. 

Murphy, J. M., OUvier, D. C, Monson, R. R.. Sobol, A. M., 
& Leighton, A. H. (1988). Incidence of depression and 
anxiety: The Stirling County Study. American Journal of 
Public Health, 78, 534-540. 

Murray, L., Kempton, C, Woolgar, M., & Hooper, R. (1993). 
Depressed mothers' speech to their infants and its relation 
to infant gender and cognitive development. Journal of 
Child Psychology and Psychiatry, 34, 1083-1 102. 



National Association of Psychiatric Treatment Centers for 
Children. (1990). The emerging role of psychiatric 
treatment centers for children. Unpublished manuscript. 

National Center for Health Statistics. (1998). Leading causes 
of death by race and sex for selected age groups: United 
States 1979-96. Rockville, MD: Author. 

National Center for Health Statistics. (1997). United States 
mortality statistics 1989-1996. Rockville, MD: Author. 

National Committee to Prevent Child Abuse. (1995). Current 
trends in child abuse reporting and fatalities: The results 
of the 1994 annual 50 state survey. Chicago: Author. 

National Institute of Mental Health. (1998). Genetics and 
mental disorders: Report of the National Institute of 
Mental Health's genetics workgroup (NIH Pubhcation 
No. 98-4268). Rockville, MD: Author. 

National Institutes of Health Consensus Statement 110. 
(1998). Diagnosis and treatment of attention deficit 
hyperactivity disorder (ADHD) [On-line]. Available: 
http://odp. od.nih.gov/ 
consensus/cons/ 1 10/1 10_statement.html 

National Mental Health Association. (1987). Invisible 
Children Project. Final report and recommendations of 
the Invisible Children Project. Alexandria, VA: Author 

National Mental Health Association. (1993). A guide for 
advocates to all systems failure. An examination of the 
results of neglecting the needs of children with serious 
emotional disturbance. Alexandria, VA: Author. 

National Research Council. (1993). Understanding child 
abuse and neglect. Panel on Research on Child Abuse 
and Neglect, Commission on Behavioral and Social 
Sciences and Education. Washington, DC: National 
Academy Press. 

Needleman, H. L., Schell, A., BeUinger, D., Leviton, A., & 
Allred, E. N. (1990). The long-term effects of exposure to 
low doses of lead in childhood. An 11 -year follow-up 
report. New England Journal of Medicine, 322, 83-88. 

Nichols, P. L., & Chen, T. C. (1981). Minimal brain 
dysfunction: A prospective study. Hillsdale, NJ: Erlbaum. 

Nolen-Hoeksema, S., & Girgus, J. S. (1994). The emergence 
of gender differences in depression during adolescence. 
Psychological Bulletin, 115, 424-443. 

Nolen-Hoeksema, S., Morrow, J., & Fredrickson, B. L. 
(1993). Response styles and the duration of episodes of 
depressed mood. Journal of Abnormal Psychology, 102, 
20-28. 

O'Carroll, P. W., & Potter, L. B., (1994). Suicide contagion 
and the reporting of suicide: Recommendations from a 
national workshop. United States Department of Health 
and Human Services. Morbidity and Mortality Weekly 
Report, 43, 9-17. 

Ohring, R., Apter, A., Ratzoni, G., Weizman, R., Tyano, S., & 
PlutchLk, R. (1996). State and trait anxiety in adolescent 
suicide attempters. Journal of the American Academy of 
Child and Adolescent Psychiatry, 35, 154-157. 



211 



Mental Health: A Report of the Surgeon General 



Olds, D., Henderson, C. R., Jr., Kitzman, H., & Cole, R. 
(1995). Effects of prenatal and infancy nurse home 
visitation on surveillance of child maltreatment. 
Pediatrics, 95, 365-372. 

Olds, D., Henderson, C. R., Jr., Cole, R., Eckenrode, J., 
Kitzman, H., Luckey, D., Pettitt, L., Sidora, K., Morris, 
P., & Powers, J. (1998). Ix)ng-term effects of nurse home 
visitation on children's criminal and antisocial behavior: 
15 year follow-up of a randomized controlled trial. 
Journal of the American Medical Association, 280, 
1238-1244. 

Olds, D., Robinson, J., Song, N., Little, C, & Hill, P. (1999). 
Reducing risks for mental disorders during the first five 
years of life: A review of preventive interventions. 
Rockville, MD: Center for Mental Health Statistics. 

Olds, D. L., Eckenrode, J., Henderson, C. R., Jr., Kitzman, H., 
Powers, J., Cole, R., Sidora, K., Morris, P., Pettitt, L. M., 
& Luckey, D. (1997). Long-term effects of home 
visitation on maternal life course and child abuse and 
neglect. Fifteen-year follow-up of a randomized trial. 
Journal of the American Medical Association, 278, 
637-643. 

Olds, D. L., Henderson, C. R., Jr., Chamberlin, R., & 
Tatelbaum, R. (1986a). Preventing child abuse and 
neglect: A randomized trial of nurse home visitation. 
Pediatrics, 78, 65-78. 

Olds, D. L., Henderson, C. R., Jr., & Kitzman, H. (1994a). 
Does prenatal and infancy nurse home visitation have 
enduring effects on qualities of parental caregiving and 
child health at 25 to 50 months of life? Pediatrics, 93, 
89-98. 

Olds, D. L., Henderson, C. R., Jr., Phelps, C, Kitzman, H., & 
Hanks, C. (1993). Effect of prenatal and infancy nurse 
home visitation on government spending. Medical Care, 
31, 155-174. 

Olds, D. L., Henderson, C. R., Jr., & Tatelbaum, R. (1994b). 
Prevention of intellectual impairment in children of 
women who smoke cigarettes during pregnancy. 
Pediatrics, 93, 228-233. 

Olds, D. L., Henderson, C. R., Jr., Tatelbaum, R., & 
Chamberlin, R. (1986b). Improving the delivery of 
prenatal care and outcomes of pregnancy: A randomized 
trial of nurse home visitation. Pediatrics, 77, 16-28. 

Olds, D. L., Henderson, C. R., Jr., Tatelbaum, R., & 
ChamberUn, R. (1988). Improving the life-course 
development of socially disadvantaged mothers: A 
randomized trial of nurse home visitation. American 
Journal of Public Health, 78, 1436-1445. 

OUendick, T. H., & King, N. J. (1998). Empirically supported 
treatments for children with phobic and anxiety disorders: 
Current status. Journal of Clinical Child Psychology, 27, 
156-167. 



Oswald, D. P., & Coutinho, M. J. (1995). Identification and 
placement of students with serious emotional disturbance. 
Part I: Correlates of state child-count data. Journal of 
Emotional and Behavioral Disorders, 3, 224—229. 

Otto, R., Greenstein, J. J., Johnson, M. K., & Friedman, R. M. 
(1992). Prevalence of mental disorders among youth in 
the juvenile justice system. In J. J. Cocozza (Ed.), 
Responding to the mental health needs of youth in the 
juvenile justice system (pp. 7-48). Seattle, WA: National 
Coalition for the Mentally 111 in the Criminal Justice 
System. 

Overholser, J. C, Adams, D. M., Lehnert, K. L., & Brinkman, 
D. C. (1995). Self-esteem deficits and suicidal tendencies 
among adolescents. Journal of the American Academy of 
Child and Adolescent Psychiatry, 34, 919-928. 

Ozonoff, S., & Cathcart, K. (1998). Effectiveness of a home 
program intervention for young children with autism. 
Journal of Autism and Developmental Disorders, 28, 
25-32. 

Patterson, G. R. (1982). Coercive family process. Eugene, OR: 
Castalia. 

Patterson, G. R. (1996). Some characteristics of a 
developmental theory for early-onset delinquency. In M. 
F. Lenzenweger & J. J. Haugaard (Eds.), Frontiers in 
developmental psychology (pp. 81-124). New York: 
Oxford University Press. 

Patterson, G. R., & Dishion, T. J. (1988). Multilevel family 
process models: Traits, interactions, and relationships. In 
R. Hinde & Stevenson-Hinde (Eds.), Relationships with 
families: Mutual influences (pp. 283-3 10). Oxford, U.K.: 
Clarendon Press. 

Patterson, G. R., Dishion, T. J., & Chamberlain, P. (1993). 
Outcomes and methodological issues relating to treatment 
of antisocial children. In T. R. Giles (Eds.), Handbook of 
effective psychotherapy (pp. 43-88). New York: Plenum 
Press. 

Pavuluri, M. N., Luk, S. L., & McGee, R. (1996). Help- 
seeking for behavior problems by parents of preschool 
children: A community study. Journal of the American 
Academy of Child and Adolescent Psychiatry, 35, 
215-222. 

Pecora, P. J., Eraser, M. W., Bennet, R. B., & Haapala, D. A. 
(1991). Placement rates of children and families served by 
intensive family preservation services programs. In M. W. 
Eraser, P. J. Pecora, & D. A. Haapala (Eds.), Families in 
crisis: The impact of intensive family preservation 
services (pp. 16-28). New York: Aldine de Gruyter. 

PeUiam, W. E. (1993). Pharmacotherapy for children with 
attention-deficit hyperactivity disorder. School Psychology 
Review, 22, 199-227. 

Pelham, W. E., Jr., Gnagy, E. M., Greenslade, K. E., & Milich, 
R. (1992). Teacher ratings of DSM-IH-R symptoms for 
the disruptive behavior disorders. Journal of the American 
Academy of Child and Adolescent Psychiatry, 31, 
210-218. 



212 



Children and Mental Health 



Pelham, W. E., & Hoza, B. (1996). Intensive treatment: A 
summer treatment program for children with ADHD. In 
E. Hibbs & H. Jensen (Eds.), Psychosocial treatment for 
child and adolescent disorders: Empirically based 
strategies for clinical practice (pp. 311-340). New York: 
American Psychological Association Press. 

Pelham, W. E., Schnedler, R. W., Bender, M.E., Miller, J., 
Nilsson, D., Budrow, M., Ronnei, M., Paluchowski, C, & 
Marks, D. (1988). The combination of behavior therapy 
and methylphenidate in the treatment of hyperactivity: A 
therapy outcome study. In L. Bloomingdale, Attention 
deficit disorders (pp. 29-48). London: Pergamon. 

Pelham, W. E., Jr., Wheeler, T., & Chronis, A. (1998). 
Empirically supported psychosocial treatments for 
attention deficit hyperactivity disorder. Journal of Clinical 
Child Psychology, 27, 190-205. 

Perry, R., Campbell, M., Adams, P., Lynch, N., Spencer, E. 
K., Curren, E. L., & Overall, J. E. (1989). Long-term 
efficacy of haloperidol in autistic children: Continuous 
versus discontinuous drug administration. Journal of the 
American Academy of Child and Adolescent Psychiatry, 
28, 87-92. 

Pfeffer, C. R. (1986). The suicidal child. New York: Guilford 
Press. 

Pfeffer, C. R., Normandin, L., & Kakuma, T. (1994). Suicidal 
children grow up: Suicidal behavior and psychiatric 
disorders among relatives. Journal of the American 
Academy of Child and Adolescent Psychiatry, 33, 
1087-1097. 

Pfeffer, C. R., Martins, P., Mann, J., Sunkenberg, M., Ice, A., 
Damore, J. P., Jr, Gallo, C, Karpenos, I., & Jiang, H. 
(1997). Child survivors of suicide: Psychosocial 
characteristics. Journal of the American Academy of Child 
and Adolescent Psychiatry, 36, 65-74. 

Phillips, D. P., Carstensen, L. L., & Paight, D. J. (1989). 
Effects of mass media news stories on suicide, with new 
evidence on the role of story content. In C. R. Pfeffer 
(Ed.), Suicide among youth: Perspectives on risk and 
prevention (pp. 101-115). Washington, DC: American 
Psychiatric Press. 

Phillips, E. L., Phillips, E. A., Fixsen, D.L., & Wolf, M. M. 
(1974). The teaching family handbook. Lawrence, KS: 
University of Kansas Printing Service. 

Pickrel, S. G., & Henggeler, S. W. (1996). Multisystemic 
therapy for adolescent substance abuse and dependence. 
Child and Adolescent Psychiatric Clinics of North 
America, 5,201-211. 

Pine, D. S. (1997). Childhood anxiety disorders. Current 
Opinion in Pediatrics, 9, 329-338. 

Pine, D. S., Trautman, P. D., Shaffer, D., Cohen, L., Davies, 
M., Stanley, M., & Parsons, B. (1995). Seasonal rhythm 
of platelet [3H]imipramine binding in adolescents who 
attempted suicide. American Journal of Psychiatry, 152, 
923-925. 



Pires, S.A. (1997). Lessons learned from the Fort Bragg 
demonstration: An overview. In S. A. Pires (Ed.), Lessons 
learned from the Fort Bragg demonstration (pp. 1-22). 
Tampa, FL: University of South Florida, Research and 
Training Center for Children's Mental Health. 

Piven, J. (1997). The biological basis of autism. Current 
Opinions in Neurobiology, 7, 708-712. 

Piven, J., & O'Leary, D. (1997). Neuroimaging in autism. In 
B. S. Peterson & M. Lewis (Eds.), Child and adolescent 
psychiatric clinics of North America: Neuroimaging (Vol. 
6 , Chap. 2, pp. 305-324). Philadelphia: W. B. Saunders. 

Plomin, R. (1986). Development, genetics, and psychology. 
Hillsdale, NJ: Erlbaum. 

Provence, S. (1985). On the efficacy of early intervention 
programs. Journal of Developmental and Behavioral 
Pediatrics, 6, 363-366. 

Puig-Antich, J., Goetz, D., Davies, M., Kaplan, T., Davies, S., 
Ostrow, L., Asnis, L., Twomey, J., Iyengar, S., & Ryan, 
N. D. (1989). A controlled family history study of 
prepubertal major depressive disorder. Archives of 
General Psychiatry, 46, 406-418. 

Putallaz, M. (1983). Predicting children's sociometric status 
from their behavior. Child Development, 54, 1417-1426. 

Quinn, K. P., & Epstein, M. H. (1998). Characteristics of 
children, youth, and famiUes served by local interagency 
systems of care. In M. H. Epstein, K. Kutash, & A. 
Duchnowski (Eds.), Outcomes for children and youth 
with behavioral and emotional disorders and their 
families (pp. 81-114). Austin, TX: Pro-Ed. 

Radloff, L. S. (1977). The CES-D scale: A self-report 
depression scale for research in the general population. 
Applied Psychological Measurement, 1, 385^01. 

Raine, A., Brennan, P., Mednick, B., & Mednick, S. A. 
(1996). High rates of violence, crime, academic problems, 
and behavioral problems in males with both early 
neuromotor deficits and unstable family environments. 
Archives of General Psychiatry, 53, 544—549. 

Raine, A., Brennan, P., & Mednick, S. A. (1997). Interaction 
between birth comphcations and early maternal rejection 
in predisposing individuals to adult violence: Specificity 
to serious, early-onset violence. American Journal of 
Psychiatry, 154, 1265-1271. 

Raine, A., Reynolds, C, Venables, P. H., Mednick, S. A., & 
Farrington, D. P. (1998). Fearlessness, stimulation- 
seeking, and large body size at age 3 years as early 
predispositions to childhood aggression at age 1 1 years. 
Archives of General Psychiatry, 55, 745-751. 

Ramey, C. T., Bryant, D. M., Wasik, B. H., Sparhng, J. J., 
Fendt, K. H., & LaVange, L. M. (1992). Infant Health 
and Development Program for low birth weight, 
premature infants: Program elements, family participation, 
and child intelligence. Pediatrics, 89, 454-465. 



213 



Mental Health: A Report of the Surgeon General 



Ramey, C. T., & Campbell, F. A. (1984). Preventive education 
for high-risk children: Cognitive consequences of the 
Carolina Abecedarian Project. American Journal on 
Mental Deficiency, 88, 515-523. 

Ramey, C. T., Yeates, K. O., & Short, E. J. (1984). The 
plasticity of intellectual development: Insights from 
preventive intervention. Child Development, 55, 
1913-1925. 

Rao, U., Ryan, N. D., Birmaher, B., Dahl, R. E., Williamson, 
D. E., Kaufman, J., Rao, R., & Nelson, B. (1995). 
Unipolar depression in adolescents: Clinical outcome in 
adulthood. Journal of the American Academy of Child 
and Adolescent Psychiatry, 34, 566-578. 

Rapin, I., & Katzman, R. (1998). Neurobiology of autism. 
Annals of Neurology, 43, 7-14. 

Rapport, M. D., & Denney, C. (1997). Titrating 
methylphenidate in children with attention- 
deficit/hyperactivity disorder: Is body mass predictive of 
clinical response? Journal of the American Academy of 
Child and Adolescent Psychiatry, 36, 523-530. 

Ranch, S. L., & Savage, C. R. (1997). Neuroimaging and 
neuropsychology of the striatum. Bridging basic science 
and clinical practice. Psychiatric Clinics of North 
America, 20, 741-768. 

Regier, D. A., Narrow, W. E., Rae, D. S., Manderscheid, R. 
W., Locke, B. Z., & Goodwin, F. K. (1993). The de facto 
U.S. mental and addictive disorders service system. 
Epidemiologic Catchment Area prospective 1-year 
prevalence rates of disorders and services. Archives of 
General Psychiatry, 50, 85-94. 

Rew, L., Resnick, M. D., & Blum, R. W. (1997). An 
exploration of help-seeking behaviors in female Hispanic 
adolescents. Family & Community Health, 20, 1-15. 

Reynolds, W. M. (1986). Reynolds adolescent depression 
scale. Odessa, TX: Psychological Assessment Resources. 

Reynolds, W. M., & Coats, K. I. (1986). A comparison of 
cognitive-behavioral therapy and relaxation training for 
the treatment of depression in adolescents. Journal of 
Consulting and Clinical Psychology, 54, 653-660. 

Rholes, W. S., Blackwell, J., Jordan, C, & Walters, C. (1980). 
A developmental study of learned helplessness. 
Developmental Psychology, 16, 616-624. 

Richters, J. E., Arnold, L. E., Jensen, P. S., Abikoff, H., 
Conners, C. K., Greenhill, L. L., Hechtman, L., Hinshaw, 
S. P., Pelham, W. E., & Swanson, J. M. (1995). NIMH 
collaborative multisite multimodal treatment study of 
children with ADHD: I. Background and rationale. 
Journal of the American Academy of Child and 
Adolescent Psychiatry, 34, 987-1000. 

Riddle, M. A., Nelson, J. C, Kleinman, C. S., Rasmusson, A., 
Leckman, J. P.. King, R. A., & Cohen, D. J. (1991). 
Sudden death in children receiving Norpramin: A review 
of three reported cases and commentary. Journal of the 
American Academy of Child and Adolescent Psychiatry, 
30, 104-108. 



Riddle, M. A., Scahill, L., King, R. A., Hardin, M. T., 
Anderson, G. M., Ort, S. I., Smith, J. C, Leckman, J. P., 
& Cohen, D. J. (1992). Double-blind, crossover trial of 
fluoxetine and placebo in children and adolescents with 
obsessive-compulsive disorder. Journal of the American 
Academy of Child and Adolescent Psychiatry, 31, 
1062-1069. 

Riddle, M. A., Subramaniam, G., & Walkup, J. T. (1998). 
Efficacy of psychiatric medications in children and 
adolescents: A review of controlled studies. Psychiatric 
Clinics of North America: Annual of Drug Therapy, 5, 
269-285. 

Rifkin, A., Doddi, S., Dicker, R., Karajgi, B., & Perl, E. 
(1989, May). Lithium in adolescence with conduct 
disorder. Paper presented at the annual meeting of the 
New Drug Clinical Evaluation Unit, Key Biscayne, PL. 

Rihmer, Z., Rutz, W., & Pihlgren, H. (1995). Depression and 
suicide on Gotland. An intensive study of all suicides 
before and after a depression-training programme for 
general practitioners. Journal of Affective Disorders, 35, 
147-152. 

Roberts, R. E., Attkisson, C. C, & Rosenblatt, A. (1998). 
Prevalence of psychopathology among children and 
adolescents. American Journal of Psychiatry, 155, 
715-725. 

Robson, K. M., & Kumar, R. (1980). Delayed onset of 
maternal affection after childbirth. British Journal of 
Psychiatry, 136, 347-353. 

Rogers, S. J. (1998). Empirically supported comprehensive 
treatments for young children with autism. Journal of 
Clinical Child Psychology, 27, 168-179. 

Roose, A. I. (1987). Treatment outcomes in an adolescent 
residential treatment center. Unpublished doctoral 
dissertation, University of Texas, Health Science Center, 
Dallas, TX. 

Rorsman, B., Grasbeck, A., Hagnell, O., Lanke, J., Ohman, R., 
Ojesjo, L., & Otterbeck, L. (1990). A prospective study of 
first-incidence depression. The Lundby Study, 1957-72. 
British Journal of Psychiatry, 156, 336-342. 

Rosado, J. W., & Elias, N. J. (1993). Ecological and psycho- 
cultural mediators in the delivery of services for urban, 
culturally diverse Hispanic clients. Professional 
Psychology: Research and Practice, 24, 450-459. 

Rosenblatt, A. (1998). Assessing the child and family 
outcomes of systems of care for youth with serious 
emotional disturbance. In M. H. Epstein, K. Kutash, & A. 
Duchnowski (Eds.), Outcomes for children and youth 
with behavioral and emotional disorders and their 
families (pp. 329-362). Austin, TX: Pro-Ed. 

Ross, D. M., & Ross, S. A. (1982). Hyperactivity: Current 
issues, research, and theory. New York: Wiley. 

Rotenberg, J. H. (1982). Development of character constancy 
of self and others. Child Development, 53, 505-515. 



214 



Children and Mental Health 



Rotheram-Borus, M. J., Piacentini, J., Miller, S., Graae, F., & 

Castro-Blanco, D. (1994). Brief cognitive-behavioral 

treatment for adolescent suicide attempters and their 

famiUes. Journal of the American Academy of Child and 

Adolescent Psychiatry, 33, 508-517. 
Rubenstein, J. S., Armentrout, J. A., Levin, S., & Herald, D. 

(1978). The parent-therapist program: Alternate care for 

emotionally disturbed children. American Journal of 

Orthopsychiatry, 48, 654-662. 
Ruiz, P. (1993). Access to health care for uninsured 

Hispanics: Policy recommendations. Hospital and 

Community Psychiatry, 44, 958-962. 
Rutter, M. (1979). Protective factors in children's responses to 

stress and disadvantage. In M. W. Kent & J. E. Rolf 

(Eds.), Primary prevention of psychopathology: Social 

competence in children (pp. 49-74). Hanover, NH: 

University Press of New England. 
Rutter, M. (1995). Clinical implications of attachment 

concepts: Retrospect and prospect. Journal of Child 

Psychology and Psychiatry. 36, 549-571. 
Rutter, M., & Giller, H. (1984). Juvenile delinquency: Trends 

and perspectives. New York: Penguin. 
Rutter, M., & Quinton, D. (1977). Psychiatric disorders: 

Ecological factors and concepts of causation. In H. 

McGurk (Ed.), Ecological factors in human development 

(pp. 173-187). Amsterdam, Holland: North-Holland. 
Rutter, M., & Sandberg, S. (1992). Psychosocial stressors: 

Concepts, causes and effects. European Child and 

Adolescent Psychiatry, 1, 3-13. 
Rutter, M., Silberg, J., O'Connor, T., & Simonoff, E. (1999). 

Genetics and child psychiatry: I. Advances in quantitative 

and molecular genetics. Journal of Child Psychology and 

Psychiatry, 40, 3-18. 
Rutter, M. L. (1986). Child psychiatry: The interface between 

cUnical and developmental research. Psychological 

Medicine, 16, 151-169. 
Ryan, N. D., Bhatara, V. S., & Perel, J. M. (1999). Mood 

stabihzers in children and adolescents. Journal of 

American Academy of Child and Adolescent Psychiatry, 

38, 529-536. 
Ryan, N. D., Puig-Antich, J., Ambrosini, P., Rabinovich, H., 

Robinson, D., Nelson, B., Iyengar, S., & Twomey, J. 

(1987). The clinical picture of major depression in 

children and adolescents. Arc/z/ves of General Psychiatry, 

44,854-861. 
Ryan, N. D., & Varma, D. (1998). Child and adolescent mood 

disorders — experience with serotonin-based therapies. 

Biological Psychiatry, 44, 336-340. 
Sabbath, J. C. (1969). The suicidal adolescent — the 

expendable child. Journal of the American Academy of 

Child Psychiatry, 8, 272-289. 
Salzinger, S., Feldman, R. S., Hammer, M., & Rosario, M. 

(1993). The effects of physical abuse on children's social 

relationships. Child Development, 64, 169-187. 



Sampson, R. J., & Laub, J. H. (1993). Crime in the making: 
Pathways and turning points through life. Cambridge, 
MA: Harvard University Press. 

Sanchez, L. E., Campbell, M., Small, A. M., Cueva, J. E., 
Armenteros, J. L., & Adams, P. B. (1996). A pilot study 
of clomipramine in young autistic children. Journal of the 
American Academy of Child and Adolescent Psychiatry, 
35, 537-544. 

Santarcangelo, S., Bruns, E. J., & Yoe, J. T. (1998). New 
directions: evaluating Vermont's statewide model of 
individualized care. In M. H. Epstein, K. Kutash, & A. 
Duchnowski (Eds.), Outcomes for children and youth 
with behavioral and emotional disorders and their 
families (pp. 117-140). Austin, TX: Pro-Ed. 

Santisteban, D. A., Szapocznik, J., Perez- Vidal, A., Kurtines, 
W. M., Murray, E. J., & LaPerriere, A. (1996). Efficacy 
of intervention for engaging youth and families into 
treatment and some variables that may contribute to 
differential effectiveness. Journal of Family Psychology, 
10, 35^H. 

Saunders, S. M. (1996). Apphcants' experience of social 
support in the process of seeking psychotherapy. 
Psychotherapy, 33, 611-621 . 

Saxe, L., & Cross, T. P. (1997). Interpreting the Fort Bragg 
Children's Mental Health Demonstration Project. The cup 
is half full. American Psychologist, 52, 553-556. 

Schorr, L. B. (1988). Within our reach: Breaking the cycle of 
disadvantage. New York: Doubleday. 

Schweitzer, R., & Dubey, D. R. (1994). Scattered-site crisis 
beds: An alternative to hospitahzation for children and 
adolescents. Hospital and Community Psychiatry, 45, 
351-354. 

Sechrest, L., & Walsh, M. (1997). Dogma or data: Bragging 
rights. American Psychologist, 52, 536-540. 

Seitz, v., Rosenbaum, L. K., & Apfel, N. H. (1985). Effects of 
family support intervention: A ten-year follow-up. Child 
Development, 56, 376-391. 

Seligman, M. E. P. (1975) Helplessness: On depression, 
development, and death. San Francisco: Freeman. 

Shadish, W. R., Montgomery, L. M., Wilson, P., Wilson, M. 
R., Bright, I., & Okwumabua, T. (1993). Effects of family 
and marital psychotherapies: A meta-analysis. Journal of 
Consulting and Clinical Psychology, 61, 992-1002. 

Shaffer, D., & Craft, L., (1999). Methods of adolescent suicide 
prevention. Journal of Clinical Psychiatry, 50(Suppl. 2), 
70-74. 

Shaffer, D., & Fisher, P. W. (1998). Diagnostic Interview 
Schedule for Children (DISC) Depression Scale (ages 11 
and over). New York: Columbia University/New York 
State Psychiatric Institute. Unpublished manuscript, 
Columbia University/New York State Psychiatric 
Institute. 



215 



Mental Health: A Report of the Surgeon General 



Shaffer, D., Fisher, P., Dulcan, M. K., Davies, M., Piacentini, 
J., Schwab-Stone, M. E., Lahey, B. B., Bourdon, K., 
Jensen, P. S., Bird, H. R., Canino, G., & Regier, D. A. 
(1996a). The NIMH Diagnostic Interview Schedule for 
Children Version 2.3 (DISC-2.3): Description, 
acceptabiUty, prevalence rates, and performance in the 
MECA Study. Methods for the Epidemiology of Child 
and Adolescent Mental Disorders Study. Journal of the 
American Academy of Child and Adolescent Psychiatry, 
35, 865-877. 

Shaffer, D., Fisher, P., Dulcan, M., Davies, M., Piacentini, J., 
Schwab-Stone, M., Lahey, B., Bourdon, K., Jensen, P., 
Bird, H., & Canino, G. R. D. (1996b). The second version 
of the NIMH Diagnostic Interview Schedule for Children 
(DlSC-2). Journal of the American Academy of Child 
and Adolescent Psychiatry, 35, 865-877. 

Shaffer, D., Garland, A., & Bacon, K. (1989). Prevention 
issues in youth suicide. In D. Shaffer, I. Philips, & N. 
Enzer (Eds.), Prevention of mental disorders, alcohol and 
drug abuse in children and adolescents. (OSAP 
Prevention Monograph 2, pp. 373^12). Rockville, MD: 
Alcohol, Drug Abuse and Mental Health Administration. 

Shaffer, D., Garland, A., Fisher, P., Bacon, K., & Vieland, V. 
(1990a). Suicide crisis centers: A critical appraisal with 
special reference to the prevention of youth suicide. In F. 
E. Goldston, C. M. Heinecke, R. S. Pynoos, & J. Yager 
(Eds.), Preventing mental health disturbance in childhood 
(pp. 135-166). Washington, DC: American Psychiatric 
Press. 

Shaffer, D., Garland, A., Vieland, V., Underwood, M., & 
Busner, C. (1991). The impact of curriculum-based 
suicide prevention programs for teenagers. Journal of the 
American Academy of Child and Adolescent Psychiatry, 
30, 588-596. 

Shaffer, D., Gould, M. S., Fisher, P., Trautment, P., Moreau, 
D., Kleinman, M., & Flory, M. (1996c). Psychiatric 
diagnosis in child and adolescent suicide. Archives of 
General Psychiatry, 53, 339-348. 

Shaffer, D., Vieland, V., Garland, A., Rojas, M., Underwood, 
M., & Busner, C. (1990b). Adolescent suicide attempters. 
Response to suicide-prevention programs. Journal of the 
American Medical Association, 264, 3151-3155. 

Shaffer, D., Craft, L. (1999). Methods of adolescent suicide 
prevention. Journal of Clinical Psychiatry, (50, (Suppl. 2), 
70-74. 

Shafii, M., Carrigan, S., Whittinghill, J. R., & Derrick, A. 
(1985). Psychological autopsy of completed suicide in 
children and adolescents. American Journal ofPsychiatry, 
142, 1061-1064. 

Sheridan, A., & Moore, L. M. (1991). Running groups for 
parents with schizophrenic adolescents: Initial experiences 
and plans for the future. Journal of Adolescence, 14, 
1-16. 



Shulman, D. A., & Athey, M. (1993). Youth emergency 
services: Total community effort, a multisystem approach. 
Child Welfare, 72, 171-179. 

Singh, N. N., Landrum, T. J., Donatelli, L. S., Hampton, C, & 
Elhs, C. R. (1994). Characteristics of children and 
adolescents with serious emotional disturbance in systems 
of care. Part I: Partial hospitalization and inpatient 
psychiatric services. Journal of Emotional and 
Behavioral Disorders, 2, 13-20. 

Smalley, S. L., Bailey, J. N., Palmer, C. G., Cantwell, D. P., 
McGough, J. J., Del'Homme, M. A., Asamow, J. R., 
Woodward, J. A., Ramsey, C, & Nelson, S. F. (1998). 
Evidence that the dopamine D4 receptor is a susceptibiUty 
gene in attention deficit hyperactivity disorder. Molecular 
Psychiatry, 3, 427^30. 

Smetana, J. G., & Kelly, M. (1989). Social cognition in 
maltreated children. In D. Cichetti & V. Carlson (Eds.), 
Child maltreatment: Theory and research on causes and 
consequences of child abuse and neglect (pp. 620-646). 
New York: Cambridge University Press. 

Smucker, M. R., Craighead, W. E., Craighead, L. W., & 
Green, B. J. (1986). Normative and reliability data for the 
Children's Depression Inventory. Journal of Abnormal 
Child Psychology, 14, 25-39. 

Snidman, N., Kagan, J., Riordan, L., & Shannon, D. C. 
(1995). Cardiac function and behavioral reactivity during 
infancy. Psychophysiology, 32, 199-207. 

Snowden, L. R., & Hu, T. W. (1997). Ethnic differences in 
mental health services among the severely mentally ill. 
Journal of Community Psychology, 25, 235-247. 

Spaccarelli, S., Cotler, S., & Penman, D. (1992). Problem- 
solving skills training as a supplement to behavioral 
parent training. Cognitive Therapy and Research, 27, 
171-186. 

Spencer, T., Biederman, J., Wilens, T., Harding, M., 
O'Donnell, D., & Griffin, S. (1996). Pharmacotherapy of 
attention-deficit hyperactivity disorder across the life 
cycle. Journal of the American Academy of Child and 
Adolescent Psychiatry, 35, 409^32. 

Spencer, T., Wilens, T., Biederman, J., Faraone, S. V., Ablon, 
J. S., & Lapey, K. (1995). A double-blind, crossover 
comparison of methylphenidate and placebo in adults with 
childhood-onset attention-deficit hyperactivity disorder. 
Archives of General Psychiatry, 52, 434-443. 

Spirito, A. (1997). Individual therapy techniques with 
adolescent suicide attempters. Crisis, 18, 62-64. 

Spirito, A., Overholser, J., Ashworth, S., Morgan, J., & 
Benedict-Drew, C. (1988). Evaluation of a suicide 
awareness curriculum for high school students. Journal of 
the American Academy of Child and Adolescent 
Psychiatry, 27,705-711. 

Sroufe, L. A., & Rutter, M. (1984). The domain of 
developmental psychopathology. Child Development, 55, 
17-29. 



216 



Children and Mental Health 



St. Lawrence, J. S., Brasfield, T. L., Jefferson, K. W., Alleyne, 
E., O'Bannon. R. E.. IH, & Shirley, A. (1995). Cognitive- 
behavioral intervention to reduce African American 
adolescents' riskfor HTV infection. Journal of Consulting 
and Clinical Psychology, 63, 221-237. 

Stanton, M. D., & Shadish, W. R. (1997). Outcome, attrition 
and family/couples treatment for drug abuse: A meta- 
analysis and review of the controlled, comparative studies. 
Psychological Bulletin, 122, 170-191. 

Stark, K. D., Reynolds, W. M., & Kaslow, N. J. (1987). A 
comparison of the relative efficacy of self-control therapy 
and a behavioral problem-solving therapy for depression 
in children. Journal of Abnormal Child Psychology, 15, 
91-113. 

Stark, K. D., Rouse, L., & Livingston, R. (1991). Treatment of 
depression during childhood and adolescence: Cognitive- 
behavioral procedures for the individual and family. In P. 
Kenall (Ed.), Child and adolescent therapy (pp. 
165-206). New York: Guilford Press. 

Steiner, H., & Lock, J. ( 1998). Anorexia nervosa and bulimia 
nervosa in children and adolescents: A review of the past 
10 years. Journal of the American Academy of Child arui 
Adolescent Psychiatry, 37, 352-359 

Stratton, K., Howe, C, & Battagha, F. C. (Eds.). (1996). Fetal 
alcohol syndrome: Diagnosis, epidemiology, prevention, 
and treatment Washington, DC: Institute of Medicine. 

Strauss, A. A., & Lehtinen, L. E. ( 1 947). Psychopathology and 
education of the brain-injured child. New York: Grune & 
Stratton. 

Strober, M., DeAntonio, M., Schmidt-Lackner, S., Pataki, C, 
Freeman, R.. Rigali, J., & Rao. U. (1999). The 
pharmacotherapy of depressive illness in adolescents: An 
open-label comparison of fluoxetine with imipramine- 
treated historical controls. Journal of Clinical Psychiatry, 
60, 164-169. 

Strober, M., Lampert, C, Schmidt, S., & Morrell. W. (1993). 
The course of major depressive disorder in adolescents: I. 
Recovery and risk of manic switching in a follow-up of 
psychotic and nonpsychotic subtypes. Journal of the 
American Academy of Child and Adolescent Psychiatry, 
32, 34-42. 

Strober, M., MorreU, W., Lampert, C, & Burroughs, J. (1990). 
Relapse following discontinuation of lithium maintenance 
therapy in adolescents with bipolar I illness: A naturalistic 
study. American Journal of Psychiatty, 147, 457-461. 

Strober, M., Schmidt-Lackner. S., Freeman, R., Bower, S., 
Lampert, C, & DeAntonio. M. (1995). Recovery and 
relapse in adolescents with bipolar affective Ulness: A 
five-year naturahstic, prospective foUowup. Journal of the 
American Academy of Child and Adolescent Psychiatry, 
34,124-131. 



Stroul, B. A. (1988). Series on community-based services for 
children and adolescents who are severely emotionally 
disturbed. Vol. 1: Home-based services. Washington, DC: 
CASSP Technical Assistance Center, Georgetown 
University Child Development Center. 

Stroul, B. A. (Ed.). (1993a). Children's mental health: 
Creating systems of care in a changing society. 
Baltimore: Paul H. Brookes. 

Stroul, B. A. (1993b). Systems of care for children and 
adolescents with severe emotional disturbances: Wliat are 
the results? Washington. DC: CASSP Technical 
Assistance Center. Georgetown University Child 
Development Center. 

Stroul, B. A., & Friedman, R. M. (1986). A system of care for 
seriously emotionally disturbed children and youth. 
Washington, DC: CASSP Technical Assistance Center, 
Georgetown University Child Development Center. 

Stroul, B. A.. & Friedman, R. M. (1988). Caring for severely 
emotionally disturbed children and youth. Principles for 
a system of care. Child Today, 17, 11-15. 

Stroul, B. A, & Friedman, R. M. (1996). A system of care for 
children and adolescents with severe emotional 
disturbance (Rev. ed.). Washington, DC: National 
Technical Assistance Center for Child Mental Health, 
Georgetown University Child Development Center. 

Stroul, B. A., Pires, S. A., & Armstrong, M. A. (1998). Health 
care reform tracking project: Tracking state managed 
care reforms as they affect children and adolescents with 
behavioral disorders and their families — 1997 impact 
analysis. Tampa, FL: University of Florida, Florida 
Mental Health Institute, Louis de la Parte Research and 
Training Center for Children's Mental Health. 

Substance Abuse and Mental Health Services Administration. 
(1993). Final notice establishing definitions for (1) 
children with a serious emotional disturbance, and (2) 
adults with a serious mental illness. Federal Register, 58, 
29422-29425. 

Sue, S., Fujino, D. C, Hu, L. T., Takeuchi, D. T., & Zane, N. 
W. (1991). Community mental health services for ethnic 
minority groups: A test of the cultural responsiveness 
hypothesis. Journal of Consulting and Clinical 
Psychology, 59, 533-540. 

Sullivan, P. F. (1995). MortaUty in anorexia nervosa. 
American Journal of Psychiatry, 152, 1073-1074. 

Swanson, J. M., Flokhart, D., Udrea, D., & Cantwell, D. 
(1995a). Clonidine in the treatment of ADHD: Questions 
about safety and efficacy. Journal of Child and 
Adolescent Psychopharmacology, 5, 301-304. 

Swanson, J. M., McBumett, K., Christian, D. L., & Wigal, T. 
(1995b). Stimulant medications and treatment of children 
with ADHD. Advances in Clinical Child Psychology, 17, 
265-3 



217 



Mental Health: A Report of the Surgeon General 



Swanson, J. M., McBumett, K., Wigal, T., & Pfiffner, L. J. 

(1993). Effect of stimulant medication on children with 

attention-deficit disorder: A review of "reviews." 

Exceptional Children, 60, 154—161. 
Swanson, J., Posner, M. I., Cantwell, D., Wigal, S., Crinella, 

F., Filipek, P., Emerson, J., Tucker, D., & Nalcioglu, O. 

(1998). Attention-deficit/hyperactivity disorder: Symptom 

domains, cognitive processes, and neural networks. In R. 

Parasuranam (Ed.), The attentive brain (pp. 445^60). 

Cambridge, MA: MIT Press. 
Swedo, S. E., Pleeter, J. D., Richter, D. M., Hoffman, C. L., 

Allen, A. J., Hamburger, S. D., Turner, E. H., Yamada, E. 

M., & Rosenthal, N. E. (1995). Rates of seasonal 

affective disorder in children and adolescents. American 

Journal of Psychiatry, 152, 1016-1019. 
Szapocznik, J., & Kurtine, W. M. (1993). Family psychology 

and cultural diversity: Opportunities for theory, research 

and application. American Psychologist, 48, 400-407. 
Szapocznik, J., Perez-Vidal, A., Brickman, A. L., Foote, F. H., 

Santisteban, D., Hervis, O., & Kurtines, W. M. (1988). 

Engaging adolescent drug abusers and their families in 

treatment: A strategic structural systems approach. 

Journal of Consulting and Clinical Psychology, 56, 

552-557. 
Takeuchi, D. T., Bui, K. V., & Kim, L. (1993). The referral of 

minority adolescents to community mental health centers. 

Journal of Health and Social Behavior, 34, 153-164. 
Takeuchi, D. T., Sue, S., & Yeh, M. (1995). Remm rates and 

outcomes from ethnicity-specific mental health programs 

in Los Angeles. American Journal of Public Health, 85, 

638-643. 
Taylor, E. (1994). Syndromes of attention deficit and 

overactivity. In M. Rutter, E. Taylor, & L. Hersov (Eds.), 

Child and adolescent psychiatry: Modem approaches 

(3rd ed., pp. 285-307). Oxford: Blackwell Scientific 

Publications. 
Thies-Flechtner, K., Muller-Oerlinghausen, B., Seibert, W., 

Walther, A., & Greil, W. (1996). Effect of prophylactic 

treatment on suicide risk in patients with major affective 

disorders. Data from a randomized prospective trial. 

Pharmacopsychiatry, 29, 103-107. 
Thomas, A., & Chess, S. (1977). Temperament and 

development. New York: Brunner/Mazel. 
Thomas, A., Chess, S., & Birch, H. (1968). Temperament and 

behavior disorders in children. New York: New York 

University Press. 
Thomas, C. R., & Holzer, C. E., IE. (1999). National 

distribution of child and adolescent psychiatrists. Journal 

of the American Academy of Child and Adolescent 

Psychiatry, 38, 9-15. 
Thompson, L., Lobb, C, Elling, R., Herman, S., 

Jurkidwewicz, T., & Helluza, C. (1997). Pathways to 

family empowerment: Effects of family-centered dehvery 

of early intervention services. Exceptional Children, 64, 

99-113. 



Thompson, R. A., Connell, J. P., & Bridges, L. J. (1988). 
Temperament, emotion, and social interactive behavior in 
the strange situation: A component process analysis of 
attachment system functioning. Child Development, 59, 
1102-1110. 

Tisher, M., & Lang, M. (1983). The Children's Depression 
Scale: Review and further developments. In D. P. 
Cantwell & G. A. Garlson (Eds.), Affective disorders in 
childhood and adolescence: An update (pp. 181-202). 
New York: Spectrum Publications. 

Todd, R. D., Neuman, R., Geller, B., Fox, L. W., & Hickok, J. 
(1993). Genetic studies of affective disorders: Should we 
be starting with childhood onset probands? Journal of the 
American Academy of Child and Adolescent Psychiatry, 
52,1164-1171. 

Toth, S. L., & Cicchetti, D. (1996). Patterns of relatedness, 
depressive symptomatology, and perceived competence in 
maltreated children. Journal of Consulting and Clinical 
Psychology, 64, 32-41. 

U.S. Department of Education. (1997). To assure the free 
appropriate public education of all children with 
disabilities. Nineteenth Annual Report to Congress on the 
Implementation of the Individuals With Disabilities 
Education Act. Washington, DC: Author. 

U.S. Office of Technology Assessment. (1986). Children's 
mental health: Problems and service — a background 
paper. Washington, DC: U.S. Government Printing 
Office. 

van IJzendoom, M. H., Goldberg, S., Kroonenberg, P. M., & 
Frenkel, O. J. (1992). The relative effects of maternal and 
child problems on the quaUty of attachment: A meta- 
analysis of attachment in clinical samples. Child 
Development, 63, 840-858. 

van IJzendoom, M. H., Juffer, F., & Duyvesteyn, M. G. 
(1995). Breaking the intergenerational cycle of insecure 
attachment: A review of the effects of attachment-based 
interventions on maternal sensitivity and infant security. 
Journal of Child Psychology and Psychiatry, 36, 
225-248. 

Varanka, T. M., Weller, R. A., Weller, E. B., & Fristad, M. A. 
(1988). Lithium treatment of manic episodes with 
psychotic features in prepubertal children. American 
Journal of Psychiatry, 145, 1557-1559. 

Velez, C. N., Johnson, J., & Cohen, P. (1989). A longitudinal 
analysis of selected risk factors for childhood 
psychopathology. Journal of the American Academy of 
Child and Adolescent Psychiatry, 28, 861-864. 

Velting, D. M., & Gould, M. S. (1997). Suicide contagion. In 
R. W. Maris & M. M. Silverman (Eds.), Review of 
suicidology (pp. 96-137). New York: Guilford Press. 

Verkes, R. J., Van der Mast, R. C, Hengeveld, M. W., Tuyl, 
J. P., Zwinderman, A. H., & Van Kempen, G. M. (1998). 
Reduction by paroxetine of suicidal behavior in patients 
with repeated suicide attempts but not major depression. 
American Journal of Psychiatry, 154, 543-547. 



218 



Children and Mental Health 



Viale-Val, G., Rosenthal, R. H., Curtiss, G., & Marohn, R. C. 
(1984). Dropout from adolescent psychotherapy: A 
preliminary study. Journal of the American Academy of 
Child Psychiatry. 23, 562-568. 

Vieland, V., Whittle, B., Garland, A., Hicks, R., & Shaffer, D. 
(1991). The impact of curriculum-based suicide 
prevention programs for teenagers: An 18-month follow- 
up. Journal of the American Academy of Child and 
Adolescent Psychiatry, 50, 811-815. 

Vincent, J., Varley, C. K., & Leger, P. (1990). Effects of 
methylphenidate on early adolescent growth. American 
Journal of Psychiatry, 147, 501-502. 

Vygotsky, L. S. (1962). Thought and language. Cambridge, 
MA: MIT Press. 

Wagner, B. M. (1997). Family risk factors for child and 
adolescent suicidal behavior. Psychological Bulletin, 121, 
246-298. 

Wagner, K. D., Birmaher, B., Carlson, G., Clarke, G., Emslie, 
G., Geller, B., Keller, M. R., Mein Kutcher, S., 
Paptheodorou, G., Ryan, N., Strober, M., & Weller, E. 
(1998, June 10-13). Safety of paroxetine and imipramine 
in the treatment of adolescent depression. Poster 
presented at the 38th annual meeting of the National 
Institute of Mental Health, New CUnical D Evaluation 
Unit, Boca Raton, FL. 

Waldman, I. D., Rowe, D. C, Abramowitz, A., Kozel, S. T., 
Mohr, J. H., Sherman, S. L., Cleveland, H. H., Sanders, 
M. L., Card, J. M., & Stever, C. (1998). Association and 
linkage of the dopamine transporter gene and attention- 
deficit hyperactivity disorder in children: Heterogeneity 
owing to diagnostic subtype and severity. American 
Journal of Human Genetics, 63, 1161 -111 6. 

Wallace, J. D., Calhoun, A. D., Powell, K. E., O'Neil, J., & 
James, S. P. (1996). Homicide and suicide among Native 
Americans, 1979-1992 (Violence Surveillance Series, 
No. 2). Atlanta: Centers for Disease Control and 
Prevention, National Center for Injury Prevention and 
Control. 

Walsh, B. T., Giardina, E. G., Sloan, R. P., Greenhill, L., & 
Goldfein, J. (1994). Effects of desipramine on autonomic 
control of the heart. Journal of the American Academy of 
Child and Adolescent Psychiatry, 33, 191-197. 

Warner, V., Mufson, L., & Weissman, M. M. (1995). 
Offspring at high and low risk for depression and anxiety: 
Mechanisms of psychiatric disorder. Journal of the 
American Academy of Child and Adolescent Psychiatry, 
34, 786-797. 

Waslick, B., & Greenhill, L. (1997). Attention- 
deficit/hyperactivity disorder. In J. M. Weiner (Ed.), 
Textbook of child and adolescent psychiatry (2nd ed., pp. 
389^10). Washington, DC: American Academy of Child 
and Adolescent Psychiatry, American Psychiatric Press. 



Webster-Stratton, C. (1998). Preventing conduct problems in 
Head Start children: Strengthening parenting 
competencies. Journal of Consulting and Clinical 
Psychology, 66, 715-730. 

Weikart, D. P. (1998). Changing early childhood development 
through educational intervention. Preventive Medicine, 
27, 233-237. 

Weinberg, N. Z., Rahdert, E., Colliver, J. D., & Glantz, M. D. 
(1998). Adolescent substance abuse: A review of the past 
10 years. Journal of the American Academy of Child and 
Adolescent Psychiatry, 37, 252-261. 

Weiner, J. M. (1997). Oppositional defiant disorder. In J. M. 
Weiner (Ed.), Textbook of child and adolescent psychiatry 
(2nd ed., pp. 459^63). Washington, DC: American 
Academy of Child and Adolescent Psychiatry, American 
Psychiatric Press. 

Weinstein, L. (1974). Evaluation of a program for re- 
educating disturbed children: A follow-up comparison 
with untreated children. Washington, DC: Department of 
Health. Education, and Welfare, Bureau for the Education 
of the Handicapped. 

Weissbourd, B., & Kagan, S. L. (1989). Family support 
programs: Catalysts for change. American Journal of 
Orthopsychiatry, 59, 20-31. 

Weissman, M. M., & Klerman, G. L. (1977). Sex differences 
and the epidemiology of depression. Archives of General 
Psychiatry, i^^, 98-111. 

Weissman. M. M., Warner, V., Wickramaratne, P., Moreau, 
D., & Olfson, M. (1997). Offspring of depressed parents. 
10 years later. Archives of General Psychiatry, 54, 
932-940. 

Weissman, M. M., Wolk, S., Goldstein, R. B., Moreau, D., 
Adams, P., Greenwald, S., Klier, C. M., Ryan, M. D., 
Dahl, R. E., & Wickramaratne, P. (1999). Depressed 
adolescents grown up. Journal of the American Medical 
Association, 281, 1707-1713. 

Weisz, J. R., Han, S. S., & Valeri, S. M. (1997). More of 
what? Issues raised by the Fort Bragg Study. American 
Psychologist, 52, 541-545. 

Weisz, J. R., Huey, S. J., & Weersing, V. R. (1998). 
Psychotherapy outcome research with children and 
adolescents. Advances in Clinical Child Psychology, 20, 
49-91. 

Weisz, J. R., & Weiss, B. (1991). Studying the "referability" 
of child clinical problems. Journal of Consulting and 
Clinical Psychology, 59, 266-273. 

Weisz, J. R., & Weiss, B. (1993). Effects of psychotherapy 
with children and adolescents . Newbury Park, CA: Sage. 

Weisz, J. R., Weiss, B., Alicke, M. D., & Klotz, M. L. (1987). 
Effectiveness of psychotherapy with children and 
adolescents: A meta-analysis for clinicians. Journal of 
Consulting and Clinical Psychology, 55, 542-549. 



219 



Mental Health: A Report of the Surgeon General 



Weisz, J. R., Weiss, B., Han, S. S., Granger, D. A., & Morton, 
T. (1995). Effects of psychotherapy with children and 
adolescents revisited: A meta-analysis of treatment 
outcome studies. Psychological Bulletin, 117, 450-468. 

Weller, E. B., Cook, S. C, Hendren, R. L., & Woolston, J. L. 
(1995). On the use of mental health services by minors: 
Report to the American Psychiatric Association Task 
Force to Study the Use of Psychiatric Hospitalization of 
Minors: A review of statistical data on the use of mental 
health services by minors. Washington, DC: American 
Psychiatric Association. 

WeUs, K. (1991). Placement of emotionally disturbed children 
in residential treatment: A review of placement criteria. 
American Journal of Orthopsychiatry, 61, 339-347. 

Wender, P. (1971). Minimal brain dysfunction in children. 
New York: Wiley-Liss. 

Werner, E. E., & Smith, R. S. (1992). Overcoming the odds: 
High risk children from birth to adulthood. New York: 
Cornell University Press. 

Wernicke, J. F., Sayler, M. E., Koke, S. C, Pearson, D. K., & 
ToUefson, G. D. (1997). Fluoxetine and concomitant 
centrally acting medication use during cUnical trials of 
depression: The absence of an effect related to agitation 
and suicidal behavior. Depression and Anxiety, 6, 31-39. 

Whitaker, A. H., Van Rossem, R., Feldman, J. F., Schonfeld, 
I. S., Pinto-Martin, J. A., Tore, C, Shaffer, D., & Paneth, 
N. (1997). Psychiatric outcomes in low-birth-weight 
children at age 6 years: Relation to neonatal cranial 
ultrasound abnormaUties. Archives of General Psychiatry, 
54^ 847-856. 

Wickramaratne, P. J., & Weissman, M. M. (1998). Onset of 
psychopathology in offspring by developmental phase and 
parental depression. Journal of the American Academy of 
Child and Adolescent Psychiatry, 37, 933-942. 

Will, M. (1998). Family support: Perspectives on the 
provision of family support services. Focal Point, 2-3, 
1-2. 

WilUams, P. G., & Hersh, J. H. (1997). A male with fetal 
valproate syndrome and autism. Developmental Medicine 
and Child Neurology, 39, 632-634. 

Wilhamson, D. E., Ryan, N. D., Birmaher, B., Dahl, R. E., 
Kaufman, J., Rao, U., & Puig-Antich, J. (1995). A case- 
control family history study of depression in adolescents. 
Journal of the American Academy of Child and 
Adolescent Psychiatry, 34, 1596-1607. 



Wilson, W. J. ( 1 987). The truly disadvantaged: The inner city, 
the underclass, and public policy . Chicago: University of 
Chicago Press. 

Winsberg, B. G., Bialer, I., Kupietz, S., Botti, E., & Balka, E. 
B. (1980). Home vs hospital care of children with 
behavior disorders. A controlled investigation. Archives 
of General Psychiatry, 37, 413^18. 

Wokaich, M. L., Hannah, J. N., Pinnock, T. Y., Baumgaertel, 
A., & Brown, J. (1996). Comparison of diagnostic criteria 
for attention-deficit hyperactivity disorder in a county- 
wide sample. Journal of the American Academy of Child 
and Adolescent Psychiatry, 35, 319-324. 

Wokaich, M. L., Lindgren, S., Stromquist, A., Milich, R., 
Davis, C, & Watson, D. (1990). Stimulant medication use 
by primary care physicians in the treatment of attention 
deficit hyperactivity disorder. Pediatrics, 86, 95-101. 

Woodward, A. M., Dwinell, A. D., & Arons, B. S. (1992). 
Barriers to mental health care for Hispanic Americans: A 
literature review and discussion. Journal of Mental Health 
Administration, 19, 224-236. 

Yatchmenoff, D. K., Koren, P. E., Friesen, B. J., Gordon, L. 
J., & Kinney, R. F. (1998). Enrichment and stress in 
famiUes caring for a child with a serious emotional 
disorder. Journal of Child and Family Studies, 7, 
129-145. 

Yeh, M., Takeuchi, D. T., & Sue, S. (1994). Asian American 
children treated in the mental health system. Journal of 
Clinical Child Psychology, 23, 5-12. 

Yoshikawa, H. (1995). Long-term effects of early childhood 
programs on social outcomes and delinquency. Future 
Child 5,51-75. 

Zahn-Waxler, C, lannotti, R., Cummings, E. M., & Denham, 
S. (1990). Antecedents of problem behaviors in children 
of depressed mothers. Development and 
Psychopathology, 2, 271-291. 

Zigler, E. F., & Styfco, S. J. (1993). Head Start and beyond: 
A national planfor extended childhood intervention. New 
Haven, CT: Yale University Press. 

Zilbovicius, M., Garreau, B., Samson, Y., Remy, P., 
Barthelemy, C, Syrota, A., & Lelord, G. (1995). Delayed 
maturation of the frontal cortex in childhood autism. 
American Journal of Psychiatry, 152, 248-252. 

Zung, W. W. K. (1965). A self-rating depression scale. 
Archives of General Psychiatry, 12, 63-70. 



220 



Chapter 4 

Adults and Mental Health 



Contents 



Chapter Overview 225 

Mental Health in Adulthood 227 

Personality Traits 227 

Self-Esteem 228 

Neuroticism 229 

Avoidance 229 

Impulsivity 229 

Sociopathy 229 

Stressful Life Events 230 

Past Trauma and Child Sexual Abuse 23 1 

Domestic Violence 231 

Interventions for Stressful Life Events 232 

Prevention of Mental Disorders 233 

Anxiety Disorders 233 

Types of Anxiety Disorders 233 

Panic Attacks and Panic Disorder 233 

Agoraphobia 234 

Specific Phobias 235 

Social Phobia 235 

Generalized Anxiety Disorder 235 

Obsessive-Compulsive Disorder 236 

Acute and Post-Traumatic Stress Disorders 237 

Etiology of Anxiety Disorders 237 

Acute Stress Response 238 

New Views About the Anatomical and Biochemical Basis of Anxiety 239 

Neurotransmitter Alterations 240 

Psychological Views of Anxiety 240 



Contents, continued 



Treatment of Anxiety Disorders 241 

Counseling and Psychotherapy 241 

Pharmacotherapy 242 

Benzodiazepines 242 

Antidepressants 242 

Buspirone 243 

Combinations of Psychotherapy and Pharmacotherapy 243 

Mood Disorders 244 

Complications and Comorbidities 244 

Clinical Depression Versus Normal Sadness 245 

Assessment: Diagnosis and Syndrome Severity 245 

Major Depressive Disorder 246 

Dysthymia 246 

Bipolar Disorder 246 

Cyclothymia 251 

Differential Diagnosis 25 1 

Etiology of Mood Disorders 25 1 

Biologic Factors in Depression 25 1 

Monoamine Hypothesis 252 

Evolving Views of Depression 252 

Anxiety and Depression 253 

Psychosocial and Genetic Factors in Depression 254 

Stressful Life Events 254 

Cognitive Factors 254 

Temperament and Personality 255 

Gender 255 

Genetic Factors in Depression and Bipolar Disorder 256 

Treatment of Mood Disorders 257 

Stages of Therapy 257 

Acute Phase Therapy 257 

Continuation Phase Therapy 261 

Maintenance Phase Therapies 261 

Specific Treatments for Episodes of Depression and Mania 261 



Contents, continued 



Treatment of Major Depressive Episodes 262 

Pharmacotherapies 262 

Alternate Pharmacotherapies 263 

Augmentation Strategies 265 

Psychotherapy and Counseling 265 

Bipolar Depression 265 

Pharmacotherapy, Psychosocial Therapy, and Multimodal Therapy 266 

Preventing Relapse of Major Depressive Episodes 267 

Treatment of Mania 267 

Acute Phase Efficacy 267 

Maintenance Treatment to Prevent Recurrences of Mania 268 

Service Delivery for Mood Disorders 269 

Schizophrenia 269 

Overview 269 

Cognitive Dysfunction 272 

Functional Impairment 272 

Cultural Variation 272 

Prevalence 273 

Prevalence of Comorbid Medical Illness 273 

Course and Recovery 274 

Gender and Age at Onset 275 

Etiology of Schizophrenia 276 

Interventions 279 

Pharmacotherapy 280 

Ethnopsychopharmacology 282 

Psychosocial Treatments 283 

Psychotherapy 283 

Family Interventions 283 

Psychosocial Rehabilitation and Skills Development 283 

Coping and Self-Monitoring 284 

Vocational Rehabilitation 285 

Service Delivery 285 

Case Management 286 

Assertive Community Treatment 286 

Psychosocial Rehabilitation Services 287 

Inpatient Hospitalization and Community Alternatives for Crisis Care 287 

Services for Substance Abuse and Severe Mental Illness 288 



Contents, continued 



Other Services And Supports 289 

Consumer Self-Help 289 

Consumer-Operated Programs 290 

Consumer Advocacy 291 

Family Self-Help 291 

Family Advocacy 292 

Human Services 292 

Housing 292 

Income, Education, and Employment 293 

Health Coverage 294 

Integrating Service Systems 295 

Conclusions 296 

References 296 



Chapter 4 



Adults and Mental Health 



Adulthood is a time for achieving productive 
vocations and for sustaining close relationships at 
home and in the community. These aspirations are 
readily attainable for adults who are mentally healthy. 
And they are within reach for adults who have mental 
disorders, thanks to major strides in diagnosis, 
treatment, and service delivery. 

This chapter reviews the current state of knowledge 
about mental health in adults, along with selected 
mental disorders: anxiety disorders, mood disorders, 
and schizophrenia. These disorders are highlighted 
largely because of their prevalence in the population 
and the burden of illness associated with each. The 
chapter then turns to service delivery, describing the 
effective organization and range of services for adults 
with the most severe mental disorders. It also reviews 
an array of other services and supports designed to 
provide comprehensive care beyond the formal 
therapeutic setting. 

Chapter Overview 

Mental health in adulthood is characterized by the 
successful performance of mental function, enabUng 
individuals to cope with adversity and to flourish in 
their education, vocation, and personal relationships. 
These are the areas of functioning most widely 
recognized by the mental health field. Yet, from the 
perspective of different cultures, these measures may 
define the concept of mental health too narrowly. As 
noted in Chapter 2, many groups, particularly ethnic 
and racial minority group members, also emphasize 
community, spiritual, and religious ties as necessary for 
mental health. The mental health profession is 
becoming more aware of the importance of reaching 
out to other cultures; an innovation termed 
"linguistically and culturally competent services" is 



pertinent both to the field' s conception of mental health 
and to the diagnosis and treatment of mental disorders. 

An assortment of traits or personal characteristics 
have been viewed as contributing to mental health, 
including self-esteem, optimism, and resilience (Alloy 
& Abramson, 1988; Seligman, 1991; histitute of 
Medicine [lOM], 1994; Beardslee & Vaillant, 1997). 
These and related traits are seen as sources of personal 
resilience needed to weather the storms of stressful life 
events. 

Stressful life events in adulthood include the 
breakup of intimate romantic relationships, death of a 
family member or friend, economic hardship, role 
conflict, work overload, racism and discrimination, 
poor physical health, accidental injuries, and 
intentional assaults on physical safety (Holmes & Rahe, 
1967; Lazarus & Folkman, 1984; Kreiger et al, 1993). 
Stressful life events in adulthood also may reflect past 
events. Severe trauma in childhood, including sexual 
and physical abuse, may persist as a stressor into 
adulthood, or may make the individual more vulnerable 
to ongoing stresses (Browne & Finkelhor, 1986). 
Although some kinds of stressful life events are 
encountered almost universally, certain demographic 
groups have greater exposure and/or vulnerability to 
their cumulative impact. These groups include women, 
younger adults, unmarried adults, African Americans, 
and individuals of lower socioeconomic status (Ulbrich 
et al, 1989; McLeod & Kessler, 1990; Turner et al., 
1995; Miranda & Green, 1999). 

Anxiety disorders are the most prevalent mental 
disorders in adults (Regier et al., 1990). The anxiety 
disorders affect twice as many women as men. A broad 
category, anxiety disorders include panic disorder, 
phobias, obsessive-compulsive disorder, post-traumatic 
stress disorder, and generalized anxiety disorder. 



225 



Mental Health: A Report of the Surgeon General 



among others. Underlying this heterogeneous group of 
disorders is a state of heightened arousal or fear in 
relation to stressful events or feelings. The biological 
manifestations of anxiety, which' are grounded in the 
"fight-or-flight" response, are unmistakable: they 
include surge in heart rate, sweating, and tensing of 
muscles. But this is certainly not the whole picture. 
Although the full array of biological causes and 
correlates of anxiety are not yet in our grasp, numerous 
effective treatments for anxiety disorders exist now. 
Treatment draws on an assortment of psychosocial and 
pharmacological approaches, administered alone or in 
combination. 

Mood disorders take a monumental toll in human 
suffering, lost productivity, and suicide. Moreover, 
when unrecognized, they can result in unnecessary 
health care use. Mood disorders rank among the top 10 
causes of worldwide disability (Murray & Lopez, 
1996). Major depression and bipolar disorder are the 
most familiar mood disorders, but there are others 
including cyclothymia (alternating manic and 
depressive states that, while protracted, do not meet 
criteria for bipolar disorder) and dysthymia (a chronic, 
albeit symptomatically milder form of depression). The 
causes of mood disorders are not fully known. They 
may be triggered by stressful life events and enduring 
stressful social conditions (e.g., poverty and 
discrimination). With the exception of bipolar disorder, 
they too, like the anxiety disorders, are twice as 
common in women as men. One subtype of mood 
disorder, seasonal affective disorder, in which episodes 
of depression tend to occur in the late fall and winter, 
is seven times more common in women than in men 
(Blumenthal, 1988). Many psychosocial and genetic 
factors interact to dictate the appearance and persis- 
tence of mood disorders, according to the biopsycho- 
social model presented in Chapter 2. 

Mood disorders, like anxiety disorders, can be 
treated with a host of effective pharmacological and 
psychosocial treatments. Either type of treatment is 
effective for about 50 to 70 percent of patients in 
outpatient settings (Depression Guideline Panel, 1993). 
Severe depression seems to resolve more quickly with 
pharmacotherapy (Depression Guideline Panel, 1993) 



and may be helped further by multimodal therapy (the 
combination of pharmacotherapy and psychotherapy) 
(Thase et al., 1997b). Despite the efficacy of treatment, 
a surprising fraction of those with mood disorders go 
untreated (Katon et al., 1992; Narrow et al., 1993; 
Wells et al., 1994; Thase, 1996). The foremost barriers 
to treatment include cost, stigma, and problems in the 
organization of service systems that contribute to the 
underrecognition of these disorders. 

Schizophrenia affects about 1 percent of the 
population, yet its severity and persistence reverberate 
throughout the mental health service system. 
Schizophrenia is marked by profound alterations in 
cognition and emotion. Symptoms frequently include 
hearing internal voices or experiencing other sensations 
not connected to an obvious source (hallucinations) and 
assigning unusual significance or meaning to normal 
events or holding false personal beliefs (delusions). 
The course of illness in schizophrenia is quite variable, 
with most people having periods of exacerbation and 
remission. Schizophrenia had once been thought to 
have a uniformly downhill course, but recent research 
dispels this view. Long-term followup studies show 
that many individuals with schizophrenia significantly 
improve and some recover (Ciompi, 1980; Harding et 
al., 1992). Although the causes of schizophrenia are not 
fully known, research points to the prominent role of 
genetic factors and to the impact of adverse 
environmental influences during early brain 
development (Tsuang et al., 1991; Weinberger & 
Lipska, 1995; Andreasen, 1997b). New pharmaco- 
logical treatments are at least as effective as past 
pharmacological treatments with fewer troubling side 
effects. 

Effective treatment of schizophrenia extends well 
beyond pharmacological therapy: it also includes 
psychosocial interventions, family interventions, and 
vocational and psychosocial rehabilitation. For those 
patients who are high service users, treatment should be 
coordinated by an interdisciplinary team that provides 
high-intensity, community-based services (Lehman & 
Steinwachs, 1998a). The prototype for this intensive 
case-management approach, which is useful for persons 
with other severe and persistent mental disorders as 



226 



Adults and Mental Health 



well, is assertive community treatment, described more 
thoroughly later in this chapter. Among the services 
included in this approach is substance abuse treatment. 
Its inclusion stems from findings that about half of 
patients with serious mental disorders (including 
schizophrenia) develop alcohol or other drug abuse 
problems (Drake & Osher, 1 997). Even though research 
generated a range of recommendations for effective 
treatment of schizophrenia, it is alarming that less than 
50 percent of patients actually receive many of the 
recommended treatments and that the gap was more 
pronounced in African Americans (Lehman & 
Steinwachs, 1998b). 

The social consequences of serious mental 
disorders — family disruption, loss of employment and 
housing — can be calamitous. Comprehensive treatment, 
which includes services that exist outside the formal 
treatment system, is crucial to ameliorate symptoms, 
assist recovery, and, to the extent that these efforts are 
successful, redress stigma. Consumer self-help 
programs, family self-help, advocacy, and services for 
housing and vocational assistance complement and 
supplement the formal treatment system. Many of these 
services are operated by consumers, that is, people who 
use mental health services themselves. The logic 
behind their leadership in delivery of these services is 
that consumers are thought to be capable of engaging 
others with mental disorders, serving as role models, 
and increasing the sensitivity of service systems to the 
needs of people with mental disorders (Mowbray et al., 
1996). 

Mental Health in Adulthood 

What constitutes mental health during the adult years? 
A widely used standard of mental health is the absence 
of a defined mental disorder. This standard has its 
limitations (discussed later), yet remains useful for 
epidemiological purposes. Epidemiology studies 
investigate the prevalence of mental disorders within 
several time frames: current, the past 12 months, and 
across a lifetime. Two well-designed national 
epidemiologic surveys estimate that about 80 percent of 
the adult population of the United States do not have a 
mental disorder during a year and hence may be 



considered "mentally healthy" (i.e., absence of a mental 
disorder) during any given year (Regier et al., 1993; 
Kessler et al., 1994). Thus, the popular notion that 
everyone is "dysfunctional" is far from the truth 
(Table 4-1). Yet, from time to time, many adults 
experience mental health problems. 

Defining mental health by the absence of mental 
disorder does not convey the full picture of mental 
health. Among its limitations, this definition excludes 
adults with mental disorders who function well 
between episodes of illness. These people often are 
considered by themselves, and by coworkers, friends, 
and families, to be "mentally healthy" in spite of a 
history of mental illness and the risk of recurrence. 

In addition to the mental health criteria cited 
earlier — that is, the successful performance of mental 
function, enabling individuals to cope with adversity 
and to flourish in their education, vocation, and 
personal relationships — a complementary approach 
defines the positive features of mental health in terms 
of attaining developmental milestones of adulthood, or 
in terms of displaying selected personality 
characteristics, traits, or attributes. Developmental 
theorist Erik Erikson viewed mental health in adulthood 
as achieving developmental tasks or milestones. 
According to Erikson' s formulation and his subsequent 
empirical research on adult men, adulthood was the 
time for overcoming what he termed "psychosocial 
crises," the resolution of which led to satisfactory 
interpersonal and sexual relationships and to the pursuit 
of broader concerns for society and future generations 
(Erikson, 1963; Vaillant, 1977). However, these 
milestones, and the developmental theories that 
underpin them, have been criticized as reflecting the 
norms of European males rather than of women and 
other cultures. 

Personality Traits 

Mental health and mental illness can be seen as the 
product of various personality traits, behavior patterns, 
and other characteristics which have roots in the 
individual's prior life experiences or biology. 



227 



Mental Health: A Report of the Surgeon General 



Table 4-1. Best estimate 1-year prevalence based on 


ECA and NCS, ages 18-54 






ECA Prevalence (%) 


NCS Prevalence (%) 


Best Estimate ** (%) 


Any Anxiety Disorder 


13.1 




18.7 


16.4 


Simple Pinobia 


8.3 




8.6 


8.3 


Social Phobia 


2.0 




7.4 


2.0 


Agoraphobia 


4.9 




3.7 


4.9 


GAD 


(1.5)* 




3.4 


3.4 


Panic Disorder 


1.6 




2.2 


1.6 


OCD 


2.4 




(0.9)* 


2.4 


PTSD 


(1.9)* 




3.6 


3.6 


■:■■»«_ 1 


Any Mood Disorder 


7.1 




11.1 


7.1 


MD Episode 


6.5 




10.1 


6.5 


Unipolar MD 


5.3 




8.9 


5.3 


Dysthymia 


1.6 




2.5 


1.6 


Biopolar 1 


1.1 




1.3 


1.1 


Biopolar II 


0.6 




0.2 


0.6 


.JHHHHH 


Schizophrenia 


1.3 







1.3 


Nonaffective Psychosis 


— 




0.2 


0.2 


Somatization 


0.2 




— 


0.2 


ASP 


2.1 




— 


2.1 


Anorexia Nervosa 


0.1 




— 


0.1 


Severe Cognitive Impairment 


1.2 




— 


1.2 


9MHHHH 


Any Disorder 


19.5 




23.4 


21.0 



'Numbers in parentheses indicate the prevalence of the disorder without any comorbidity. These rates were calculated using the NCS 
data for GAD and PTSD, and the ECA data for OCD. The rates were not used in calculating the any anxiety disorder and any disorder 
totals for the ECA and NCS columns. The undupllcated GAD and PTSD rates were added to the best estimate total for any anxiety 
disorder (3.3%) and any disorder (1.5%). 

**ln developing best-estimate 1 -year prevalence rates from the two studies, a conservative procedure was followed that had previously 
been used in an independent scientific analysis comparing these two data sets (Andrews, 1 995). For any mood disorder and any anxiety 
disorder, the lower estimate of the two surveys was selected, which for these data was the ECA. The best estimate rates for the 
individual mood and anxiety disorders were then chosen from the ECA only, in order to maintain the relationships between the individual 
disorders. For other disorders that were not covered in both surveys, the available estimate was used. 

Key to abbreviations: ECA, Epidemiologic Catchment Area; NCS, National Comorbidity Study; GAD, generalized anxiety disorder; 
OCD, obsessive-compulsive disorder; PTSD, post-traumatic stress disorder; MD, major depression; ASP, antisocial personality 
disorder. 

Source: D. Regier, W. Narrow, & D. Rae, personal communication, 1999 



Personality traits are thought to confer either beneficial 
or detrimental effects on mental health during adult- 
hood. Here too, however, there may be insufficient 
attention to gender and culture. The culture -bound 
nature of much of behavior has limited widespread 
predictive validity of personality research (Mischel & 
Shoda, 1968). With this caveat in mind, a brief 
summary of healthy and maladaptive characteristics 
follows. 



Self-Esteem 

Self-esteem refers to an abiding set of beliefs about 
one's own worth, competence, and abilities to relate to 
others (Vaughan & Oldham, 1997). Self-esteem also 
has been conceptualized as buffering the individual 
from adverse life events. Emotional well-being is often 
associated with a slightly positive, yet realistic, outlook 
(Alloy & Abramson, 1988). The opposite outlook is 



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Adults and Mental Health 



characterized by pessimism, demoralization, or minor 
symptoms of anxiety and depression. One seminal 
aspect of self-esteem has garnered much research 
attention: self-efficacy (Bandura, 1977). Self-efficacy 
is defined as confidence in one's own abilities to cope 
with adversity, either independently or by obtaining 
appropriate assistance from others. Self-efficacy is a 
major component of the construct known as resilience 
(i.e., the ability to withstand and overcome adversity). 
Other components of resilience include intelligence and 
problem solving, although resilience is also facilitated 
by having adequate social support (Beardslee & 
Vaillant, 1997). 

Neuroticism 

Neuroticism is a construct that refers to a broad pattern 
of psychological, emotional, and psychophysiologic 
reactivity (Eysenck & Eysenck, 1975). The opposite of 
neuroticism is stability or equanimity, which are major 
components of mental health. A high level of 
neuroticism is associated with a predisposition toward 
recognizing the dangerous, harmful, or defeating 
aspects of a situation and the tendency to respond with 
worry, anticipatory anxiety, emotionality, pessimism, 
and dissatisfaction. Neuroticism is associated with a 
greater risk of early-onset depressive and anxiety 
disorders (Clark et al., 1994). Neuroticism also may be 
linked to a particular cognitive attributional style in 
which life events are perceived to be large in impact 
and more difficult to change (Alloy et al., 1984). For 
example, this attributional style is embodied by 
pessimists who see every setback or failure as lasting 
forever, undermining everything, and being their fault 
(Seligman, 1991). Neuroticism also is associated with 
more rigid or distorted attitudes and beliefs about one' s 
competence (Beck, 1976). 

Avoidance 

Avoidance describes an exaggerated predisposition to 
withdraw from novel situations and to avoid personal 
challenges as threats. This is the behavioral state that 
often accompanies the distress of someone who has a 
high level of neuroticism and low self-efficacy 
(Vaughan & Oldham, 1997). Closely related to the 



characteristics of behavioral inhibition or introversion, 
the trait of avoidance appears to be partly inherited and 
is associated with shyness, anxiety, and depressive 
disorders in both childhood and adult life, as well as the 
subsequent development of substance abuse disorders 
(Vaughan & Oldham, 1997; Kagan et al, 1988). The 
people with low levels of harm avoidance are described 
as "healthy extroverts" and are characterized by 
confident, carefree, or outgoing behaviors. 

Impulsivity 

Impulsivity is a trait that is associated with poor 
modulation of emotions, especially anger, difficulty 
delaying gratification, and novelty seeking. There is 
some developmental continuity between high levels of 
impulsivity in childhood and several adult mental 
disorders, including attention deficit hyperactivity 
disorder, bipolar disorder, and substance abuse 
disorders (Svrakic et al., 1993; Rothbart & Ahadi, 
1994). Impulsivity also is associated with physical 
abuse (both as victim and, subsequently, as perpetrator) 
and antisocial personality traits (Vaughan & Oldham, 
1997). 

Sociopathy 

This set of traits and behaviors refers to the 
predisposition to engage in dishonest, hurtful, 
unfaithful, and at times dangerous conduct to benefit 
one's own ends. The opposite of sociopathy may be 
referred to as character or scrupulosity. In its full form, 
sociopathy is referred to as antisocial personality 
disorder (DSM-IV). Sociopathy is characterized by a 
tendency and ability to disregard laws and rules, 
difficulties reciprocating within empathic and intimate 
relationships, less internalization of moral standards 
(i.e., a weaker conscience or superego), and an 
insensitivity to the needs and rights of others. People 
scoring high in sociopathy often have problems with 
aggressivity and are overrepresented among criminal 
populations. Although not invariably associated with 
criminality, sociopathy is associated with problematic, 
unethical, and morally questionable conduct in the 
workplace and within social systems. Marked 
sociopathy is much more common among men than 



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women, although several other disorders (borderline 
and histrionic personality disorders and somatization 
disorder) are overrepresented among women within the 
same famihes (Widiger & Costa, 1994). 

In summary, the various traits and behavioral 
patterns that epitomize strong mental health do not, of 
course, exist in a vacuum: they develop in a social 
context, and they underpin people's ability to handle 
psychological and social adversity and the exposure to 
stressful life events. Furthermore, as reviewed in 
Chapter 3, severe or repeated trauma during youth may 
have enduring effects on both neurobiological and 
psychological development, altering stress responsivity 
and adult behavior patterns. Perhaps the best 
documented evidence of such enduring effects has been 
shown in young adults who experienced severe sexual 
or physical abuse in childhood. These individuals 
experience a greatly increased risk of mood, anxiety, 
and personality disorders throughout adult life. 

Stressful Life Events 

The most common psychological and social stressors in 
adult life include the breakup of intimate romantic 
relationships, death of a family member or friend, 
economic hardships, racism and discrimination, poor 
physical health, and accidental and intentional assaults 
on physical safety (Holmes & Rahe, 1967; Lazarus & 
Folkman, 1984; Kreiger et al., 1993). Although some 
stressors are so powerful that they would evoke 
significant emotional distress in most otherwise 
mentally healthy people, the majority of stressful life 
events do not invariably trigger mental disorders. 
Rather, they are more likely to spawn mental disorders 
in people who are vulnerable biologically, socially, 
and/or psychologically (Lazarus & Folkman, 1984; 
Brown & Harris, 1989; Kendler et al., 1995). 
Understanding variability among individuals to a 
stressful life event is a major challenge to research. 
Groups at greater statistical risk include women, young 
and unmarried people, African Americans, and 
individuals with lower socioeconomic status 
(Ulbrichet al., 1989;McLeod&Kessler, 1990; Turner 
et al., 1995; Miranda & Green, 1999). 



Divorce is a common example. Approximately one- 
half of all marriages now end in divorce, and about 30 
to 40 percent of those undergoing divorce report a 
significant increase in symptoms of depression and 
anxiety (Brown & Harris, 1989). Vulnerability to 
depression and anxiety is greater among those with a 
personal history of mental disorders earlier in life and 
is lessened by strong social support. For many, divorce 
conveys additional economic adversities and the stress 
of single parenting. Single mothers face twice the risk 
of depression as do married mothers (Brown & Moran, 
1997). 

The death of a child or spouse during early or 
midadult life is much less common than divorce but 
generally is of greater potency in provoking emotional 
distress (Kim & Jacobs, 1995). Rates of diagnosable 
mental disorders during periods of grief are attenuated 
by the convention not to diagnose depression during the 
first 2 months of bereavement (Clayton & Darvish, 
1979). In fact, people are generally unlikely to seek 
professional treatment during bereavement unless the 
severity of the emotional and behavioral disturbance is 
incapacitating. 

A majority of Americans never will confront the 
stress of surviving a severe, life -threatening accident or 
physical assault (e.g., mugging, robbery, rape); 
however, some segments of the population, particularly 
urban youths and young adults, have exposure rates as 
high as 25 to 30 percent (Helzer et al., 1987; Breslau et 
al., 1991). Life-threatening trauma frequently provokes 
emotional and behavioral reactions that jeopardize 
mental health. In the most fully developed form, this 
syndrome is called post-traumatic stress disorder 
(DSM-FV), which is described later in this chapter. 
Women are twice as likely as men to develop post- 
traumatic stress disorder following exposure to life- 
threatening trauma (Breslau et al, 1998.) 

More familiar to many Americans is the chronic 
strain that poor physical health and relationship 
problems place on day-to-day well-being. Relationship 
problems include unsatisfactory intimate relationships; 
conflicted relationships with parents, siblings, and 
children; and "falling-out" with coworkers, friends, and 



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Adults and Mental Health 



neighbors. In mid-adult life, the stress of caretaking for 
elderly parents also becomes more common. 

Relationship problems at least double the risk of 
developing a mental disorder, although they are less 
immediately threatening or potentially cataclysmic than 
divorce or the death of a spouse or child (Brown & 
Harris, 1989). Finally, cumulative adversity appears to 
be more potent than stressful events in isolation as a 
predictor of psychological distress and mental disorders 
(Turner & Lloyd, 1995). 

Past Trauma and Child Sexual Abuse 

Severe trauma in childhood may have enduring effects 
into adulthood (Browne & Finkelhor, 1986). Past 
trauma includes sexual and physical abuse, and parental 
death, divorce, psychopathology, and substance abuse 
(reviewed in Turner & Lloyd, 1995). 

Child sexual abuse is one of the most common 
stressors, with effects that persist into adulthood. It 
disproportionately affects females. Although 
definitions are still evolving, child sexual abuse is often 
defined as forcible touching of breasts or genitals or 
forcible intercourse (including anal, oral, or vaginal 
sex) before the age of 16 or 18 (Goodman et al., 1997). 
Epidemiology studies of adults in varying segments of 
the community have found that 15 to 33 percent of 
females and 13 to 16 percent of males were sexually 
abused in childhood (Polusny & Follette, 1995). A 
recent, large epidemiological study of adults in the 
general community found a lower prevalence (12.8 
percent for females and 4.3 percent for males); 
however, the definition of sexual abuse was more 
restricted than in past studies (MacMillan et al., 1997). 
Sexual abuse in childhood has a mean age of onset 
estimated at 7 to 9 years of age (Polusny & Follette, 
1995). In over 25 percent of cases of child sexual 
abuse, the offense was committed by a parent or parent 
substitute (Sedlak & Broadhurst, 1996). 

The long-term consequences of past childhood 
sexual abuse are profound, yet vary in expression. They 
range from depression and anxiety to problems with 
social functioning and adult interpersonal relationships 
(Polusny & Follette, 1995). Post-traumatic stress 
disorder is a common sequela, found in 33 to 86 



percent of adult survivors of child sexual abuse 
(Polusny & Follette, 1995). In a recent review, Weiss 
et al. (1999) found that sexual abuse was a specific risk 
factor for adult-onset depression and twice as many 
women as men reported a history of abuse. Other long- 
term effects include self-destructive behavior, social 
isolation, poor sexual adjustment, substance abuse, and 
increased risk of re victimization (Browne & Finkelhor, 
1986; Briere, 1992). 

Very few treatments specifically for adult survivors 
of childhood abuse have been studied in randomized 
controlled trials (lOM, 1998). Group therapy and 
Interpersonal Transaction group therapy were found to 
be more effective for female survivors than an 
experimental control condition that offered a less 
appropriate intervention (Alexander etal., 1989, 1991). 
In the practice setting, most psychosocial and 
pharmacological treatments are tailored to the primary 
diagnosis, which, as noted above, varies widely and 
may not attend to the special needs of those also 
reporting abuse history. 

Domestic Violence 

Domestic violence is a serious and startlingly common 
public health problem with mental health consequences 
for victims, who are overwhelmingly female, and for 
children who witness the violence. Domestic violence 
(also known as intimate partner violence) features a 
pattern of physical and sexual abuse, psychological 
abuse with verbal intimidation, and/or social isolation 
or deprivation. Estimates are that 8 to 17 percent of 
women are victimized annually in the United States 
(Wilt & Olsen, 1996). Pinpointing the prevalence is 
hindered by variations in the way domestic violence is 
defined and by problems in detection and 
underreporting. Women are often fearful that their 
reporting of domestic violence will precipitate 
retaliation by the batterer, a fear that is not unwarranted 
(Sisley et al., 1999). 

Victims of domestic violence are at increased risk 
for mental health problems and disorders as well as 
physical injury and death. Domestic violence is 
considered one of the foremost causes of serious injury 
to women ages 15 to 44, accounting for about 30 



231 



Mental Health: A Report of the Surgeon General 



percent of all acute injuries to women seen in 
emergency departments (Wilt & Olsen, 1996). 
According to the U.S. Department of Justice, females 
were victims in about 75 percent of the almost 2,000 
homicides between intimates in 1996 (cited in Sisley et 
al., 1999). The mental health consequences of domestic 
violence include depression, anxiety disorders (e.g., 
post-traumatic stress disorder), suicide, eating 
disorders, and substance abuse (lOM, 1998; Eisenstat 
& Bancroft, 1999). Children who witness domestic 
violence may suffer acute and long-term emotional 
disturbances, including nightmares, depression, 
learning difficulties, and aggressive behavior. Children 
also become at risk for subsequent use of violence 
against their dating partners and wives (el-Bayoumi et 
al., 1998; NRC, 1998; Sisley et al., 1999). 

Mental health interventions for victims, children, 
and batterers are highly important. Lidividual 
counseling and peer support groups are the 
interventions most frequently used by battered women. 
However, there is a lack of carefully controlled, 
methodologically robust studies of interventions and 
their outcomes, according to a report by the Institute of 
Medicine and National Research Council (lOM, 1998). 
A research agenda for violence against women was 
developed (lOM, 1996) and has served as an impetus 
for an ongoing research program sponsored by the U.S. 
Departments of Justice and Health and Human 
Services. Clearly, there is an urgent need for 
development and rigorous evaluation of prevention 
programs to safeguard against intimate partner violence 
and its impact on children. 

Interventions for Stressful Life Events 

Stressful life events, even for those at the peak of 
mental health, erode quality of life and place people at 
risk for symptoms and signs of mental disorders. There 
is an ever-expanding list of formal and informal 
interventions to aid individuals coping with adversity. 
Sources of informal interventions include family and 
friends, education, community services, self-help 
groups, social support networks, religious and spiritual 
endeavors, complementary healers, and physical 
activities. As valuable as these activities may be for 



promoting mental health, they have received less 
research attention than have interventions for mental 
disorders. Nevertheless, there are selected interventions 
to help people cope with stressors, such as bereavement 
programs and programs for caregivers (see Chapter 5) 
as well as couples therapy and physical activity. 

Couples therapy is the umbrella term applied to 
interventions that aid couples in distress. The best 
studied interventions are behavioral couples therapy, 
cognitive-behavioral couples therapy, and emotion- 
focused couples therapy. A recent review article 
evaluated the body of evidence on the effectiveness of 
couples therapy and programs to prevent marital 
discord (Christensen & Heavey, 1999). The review 
found that about 65 percent of couples in therapy did 
improve, whereas 35 percent of control couples also 
improved. Couples therapy ameliorates relationship 
distress and appears to alleviate depression. The gains 
from couples therapy generally last through 6 months, 
but there are few long-term assessments (Christensen & 
Heavey, 1999). Similarly, interventions to prevent 
marital discord yield short-term improvements in 
marital adjustment and stability, but there is 
insufficient study of long-term outcomes. The 
prevention programs receiving the most study are the 
Couple Communication Program, Relationship 
Enhancement, and the Prevention and Relationship 
Enhancement Program (Christensen & Heavey, 1999). 
Greater research is needed to overcome gaps in 
knowledge and to extend findings to a broader array of 
programs, to diverse populations of couples, and to a 
wider set of outcomes, including effects on children. 

Physical activities are a means to enhance somatic 
health as well as to deal with stress. A recent Surgeon 
General's Report on Physical Activity and Health 
evaluated the evidence for physical activities serving to 
enhance mental health (U.S. Department of Health and 
Human Services [DHHS], 1996). Aerobic physical 
activities, such as brisk walking and running, were 
found to improve mental health for people who report 
symptoms of anxiety and depression and for those who 
are diagnosed with some forms of depression. The 
mental health benefits of physical activity for 
individuals in relatively good physical and mental 



232 



Adults and Mental Health 



health were not as evident, but the studies did not have 
sufficient rigor from which to draw unequivocal 
conclusions (DHHS, 1996). 

Prevention of Mental Disorders 

A promising development in prevention of a specific 
mental disorder in adults occurred with the publication 
of results from the San Francisco Depression Research 
Project (Munoz et al., 1995). This study investigated 
150 primary care patients who did not meet diagnostic 
criteria for depression and who were being seen in a 
public clinic for other problems. They were randomized 
to either psychoeducation — an 8-week cognitive 
behavioral course to help them control and manage 
moods — or to a control condition. One year later, those 
who received psychoeducation were found to have 
developed significantly fewer depression symptoms 
than members of the control group. This trial is 
noteworthy in two major respects: it was a randomized 
controlled trial and its participants were low-income 
individuals, with high representation of all major 
minority groups. Low-income individuals are 
considered a high-risk population because of studies 
documenting their higher prevalence of mental 
disorders. This study demonstrated in a 
methodologically rigorous fashion that depression may 
be preventable in some cases. It serves as a model for 
extending the concept of prevention to many mental 
disorders. Prevention research is vitally important and 
needs to be enhanced. 



and without a history of panic disorder), generalized 
anxiety disorder, specific phobia, social phobia, 
obsessive-compulsive disorder, acute stress disorder, 
and post-traumatic stress disorder (DSM-IV). hi 
addition, there are adjustment disorders with anxious 
features, anxiety disorders due to general medical 
conditions, substance-induced anxiety disorders, and 
the residual category of anxiety disorder not otherwise 
specified (DSM-IV). 

Anxiety disorders not only are common in the 
United States, but they are ubiquitous across human 
cultures (Regier et al., 1993; Kessler et al., 1994; 
Weissman et al., 1997). In the United States, 1-year 
prevalence for all anxiety disorders among adults ages 
18 to 54 exceeds 16 percent (Table 4-1), and there is 
significant overlap or comorbidity with mood and 
substance abuse disorders (Regier et al., 1990; 
Goldberg & Lecrubier, 1995; Magee et al., 1996). The 
longitudinal course of these disorders is characterized 
by relatively early ages of onset, chronicity, relapsing 
or recurrent episodes of illness, and periods of 
disability (Keller & Hanks, 1994; Gorman & Coplan, 
1996; Liebowitz, 1997; Marcus et al., 1997). Although 
few psychological autopsy studies of adult suicides 
have included a focus on comorbid conditions (Conwell 
& Brent, 1995), it is likely that the rate of comorbid 
anxiety in suicide is underestimated. Panic disorder and 
agoraphobia, particularly, are associated with increased 
risks of attempted suicide (Hornig & McNally, 1995; 
American Psychiatric Association, 1998). 



Anxiety Disorders 

The anxiety disorders are the most common, or 
frequently occurring, mental disorders. They 
encompass a group of conditions that share extreme or 
pathological anxiety as the principal disturbance of 
mood or emotional tone. Anxiety, which may be 
understood as the pathological counterpart of normal 
fear, is manifest by disturbances of mood, as well as of 
thinking, behavior, and physiological activity. 

Types of Anxiety Disorders 

The anxiety disorders include panic disorder (with and 
without a history of agoraphobia), agoraphobia (with 



Panic Attacks and Panic Disorder 

A panic attack is a discrete period of intense fear or 
discomfort that is associated with numerous somatic 
and cognitive symptoms (DSM-IV). These symptoms 
include palpitations, sweating, trembling, shortness of 
breath, sensations of choking or smothering, chest pain, 
nausea or gastrointestinal distress, dizziness or 
lightheadedness, tingling sensations, and chills or 
blushing and "hot flashes." The attack typically has an 
abrupt onset, building to maximum intensity within 10 
to 15 minutes. Most people report a fear of dying, 
"going crazy," or losing control of emotions or 
behavior. The experiences generally provoke a strong 



233 



Mental Health: A Report of the Surgeon General 



urge to escape or flee the place where the attack begins 
and, when associated with chest pain or shortness of 
breath, frequently results in seeking aid from a hospital 
emergency room or other type of urgent assistance. Yet 
an attack rarely lasts longer than 30 minutes. Current 
diagnostic practice specifies that a panic attack must be 
characterized by at least four of the associated somatic 
and cognitive symptoms described above. The panic 
attack is distinguished from other forms of anxiety by 
its intensity and its sudden, episodic nature. Panic 
attacks may be further characterized by the relationship 
between the onset of the attack and the presence or 
absence of situational factors. For example, a panic 
attack may be described as unexpected, situationally 
bound, or situationally predisposed (usually, but not 
invariably occurring in a particular situation). There are 
also attenuated or "limited symptom" forms of panic 
attacks. 

Panic attacks are not always indicative of a mental 
disorder, and up to 10 percent of otherwise healthy 
people experience an isolated panic attack per year 
(Barlow, 1988; Klerman et al., 1991). Panic attacks 
also are not limited to panic disorder. They commonly 
occur in the course of social phobia, generalized 
anxiety disorder, and major depressive disorder 
(DSM-IV). 

Panic disorder is diagnosed when a person has 
experienced at least two unexpected panic attacks and 
develops persistent concern or worry about having 
further attacks or changes his or her behavior to avoid 
or minimize such attacks. Whereas the number and 
severity of the attacks varies widely, the concern and 
avoidance behavior are essential features. The 
diagnosis is inapplicable when the attacks are presumed 
to be caused by a drug or medication or a general 
medical disorder, such as hyperthyroidism. 

Lifetime rates of panic disorder of 2 to 4 percent 
and 1-year rates of about 2 percent are documented 
consistently in epidemiological studies (Kessler et al., 
1994; Weissman et al., 1997) (Table 4-1). Panic 
disorder is frequently complicated by major depressive 
disorder (50 to 65 percent lifetime comorbidity rates) 
and alcoholism and substance abuse disorders (20 to 30 
percent comorbidity) (Keller & Hanks, 1994; Magee et 



al., 1996; Liebowitz, 1997). Panic disorder is also 
concomitantly diagnosed, or co-occurs, with other 
specific anxiety disorders, including social phobia (up 
to 30 percent), generalized anxiety disorder (up to 25 
percent), specific phobia (up to 20 percent), and 
obsessive-compulsive disorder (up to 10 percent) 
(DSM-IV). As discussed subsequently, approximately 
one-half of people with panic disorder at some point 
develop such severe avoidance as to warrant a separate 
description, panic disorder with agoraphobia. 

Panic disorder is about twice as common among 
women as men (American Psychiatric Association, 
1998). Age of onset is most common between late 
adolescence and midadult life, with onset relatively 
uncommon past age 50. There is developmental 
continuity between the anxiety syndromes of youth, 
such as separation anxiety disorder. Typically, an early 
age of onset of panic disorder carries greater risks of 
comorbidity, chronicity, and impairment. Panic 
disorder is a familial condition and can be 
distinguished from depressive disorders by family 
studies (Rush et al., 1998). 

Agoraphobia 

The ancient term agoraphobia is translated from Greek 
as fear of an open marketplace. Agoraphobia today 
describes severe and pervasive anxiety about being in 
situations from which escape might be difficult or 
avoidance of situations such as being alone outside of 
the home, traveling in a car, bus, or airplane, or being 
in a crowded area (DSM-IV). 

Most people who present to mental health 
specialists develop agoraphobia after the onset of panic 
disorder (American Psychiatric Association, 1998). 
Agoraphobia is best understood as an adverse 
behavioral outcome of repeated panic attacks and the 
subsequent woiTy, preoccupation, and avoidance 
(Barlow, 1988). Thus, the formal diagnosis of panic 
disorder with agoraphobia was established. However, 
for those people in communities or clinical settings 
who do not meet full criteria for panic disorder, the 
formal diagnosis of agoraphobia without history of 
panic disorder is used (DSM-IV). 



234 



Adults and Mental Health 



The 1-year prevalence of agoraphobia is about 5 
percent (Table 4-1). Agoraphobia occurs about two 
times more commonly among women than men (Magee 
et al., 1996). The gender difference may be attributable 
to social-cultural factors that encourage, or permit, the 
greater expression of avoidant coping strategies by 
women (DSM-IV), although other explanations are 
possible. 

Specific Phobias 

These common conditions are characterized by marked 
fear of specific objects or situations (DSM-IV). 
Exposure to the object of the phobia, either in real life 
or via imagination or video, invariably elicits intense 
anxiety, which may include a (situationally bound) 
panic attack. Adults generally recognize that this 
intense fear is irrational. Nevertheless, they typically 
avoid the phobic stimulus or endure exposure with 
great difficulty. The most common specific phobias 
include the following feared stimuli or situations: 
animals (especially snakes, rodents, birds, and dogs); 
insects (especially spiders and bees or hornets); 
heights; elevators; flying; automobile driving; water; 
storms; and blood or injections. 

Approximately 8 percent of the adult population 
suffers from one or more specific phobias in 1 year 
(Table 4-1). Much higher rates would be recorded if 
less rigorous diagnostic requirements for avoidance or 
functional impairment were employed. Typically, the 
specific phobias begin in childhood, although there is 
a second "peak" of onset in the middle 20s of 
adulthood (DSM-IV). Most phobias persist for years or 
even decades, and relatively few remit spontaneously 
or without treatment. 

The specific phobias generally do not result from 
exposure to a single traumatic event (i.e., being bitten 
by a dog or nearly drowning) (Marks, 1969). Rather, 
there is evidence of phobia in other family members 
and social or vicarious learning of phobias (Cook & 
Mineka, 1989). Spontaneous, unexpected panic attacks 
also appear to play a role in the development of specific 
phobia, although the particular pattern of avoidance is 
much more focal and circumscribed. 



Social Pliobia 

Social phobia, also known as social anxiety disorder, 
describes people with marked and persistent anxiety in 
social situations, including performances and public 
speaking (Ballenger et al., 1998). The critical element 
of the fearfulness is the possibility of embarrassment or 
ridicule. Like specific phobias, the fear is recognized 
by adults as excessive or unreasonable, but the dreaded 
social situation is avoided or is tolerated with great 
discomfort. Many people with social phobia are 
preoccupied with concerns that others will see their 
anxiety symptoms (i.e., trembling, sweating, or 
blushing); or notice their halting or rapid speech; or 
judge them to be weak, stupid, or "crazy." Fears of 
fainting, losing control of bowel or bladder function, or 
having one' s mind going blank are also not uncommon. 
Social phobias generally are associated with significant 
anticipatory anxiety for days or weeks before the 
dreaded event, which in turn may further handicap 
performance and heighten embarrassment. 

The 1-year prevalence of social phobia ranges 
from 2 to 7 percent (Table 4-1), although the lower 
figure probably better captures the number of people 
who experience significant impairment and distress. 
Social phobia is more common in women (Wells et al., 
1994). Social phobia typically begins in childhood or 
adolescence and, for many, it is associated with the 
traits of shyness and social inhibition (Kagan et al., 
1988). A public humiliation, severe embarrassment, or 
other stressful experience may provoke an 
intensification of difficulties (Barlow, 1988). Once the 
disorder is established, complete remissions are 
uncommon without treatment. More commonly, the 
severity of symptoms and impairments tends to 
fluctuate in relation to vocational demands and the 
stability of social relationships. Preliminary data 
suggest social phobia to be familial (Rush et al., 1998). 

Generalized Anxiety Disorder 

Generalized anxiety disorder is defined by a protracted 
(> 6 months' duration) period of anxiety and worry, 
accompanied by multiple associated symptoms (DSM- 
IV). These symptoms include muscle tension, easy 
fatiguability, poor concentration, insomnia, and 



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Mental Health: A Report of the Surgeon General 



irritability. In youth, the condition is known as 
overanxious disorder of childhood. In DSM-IV, an 
essential feature of generalized anxiety disorder is that 
the anxiety and worry cannot be attributable to the 
more focal distress of panic disorder, social phobia, 
obsessive-compulsive disorder, or other conditions. 
Rather, as implied by the name, the excessive worries 
often pertain to many areas, including work, 
relationships, finances, the well-being of one's family, 
potential misfortunes, and impending deadlines. 
Somatic anxiety symptoms are common, as are 
sporadic panic attacks. 

Generalized anxiety disorder occurs more often in 
women, with a sex ratio of about 2 women to 1 man 
(Brawman-Mintzer & Lydiard, 1996). The 1-year 
population prevalence is about 3 percent (Table 4-1). 
Approximately 50 percent of cases begin in childhood 
or adolescence. The disorder typically runs a 
fluctuating course, with periods of increased symptoms 
usually associated with life stress or impending 
difficulties. There does not appear to be a specific 
familial association for general anxiety disorder. 
Rather, rates of other mood and anxiety disorders 
typically are greater among first-degree relatives of 
people with generalized anxiety disorder (Kendler et 
al., 1987). 

Obsessive-Compulsive Disorder 

Obsessions are recurrent, intrusive thoughts, impulses, 
or images that are perceived as inappropriate, 
grotesque, or forbidden (DSM-IV). The obsessions, 
which elicit anxiety and marked distress, are termed 
"ego-alien" or "ego-dystonic" because their content is 
quite unlike the thoughts that the person usually has. 
Obsessions are perceived as uncontrollable, and the 
sufferer often fears that he or she will lose control and 
act upon such thoughts or impulses. Common themes 
include contamination with germs or body fluids, 
doubts (i.e., the worry that something important has 
been overlooked or that the sufferer has unknowingly 
inflicted harm on someone), order or symmetry, or loss 
of control of violent or sexual impulses. 



Compulsions are repetitive behaviors or mental acts 
that reduce the anxiety that accompanies an obsession 
or "prevent" some dreaded event from happening 
(DSM-IV). Compulsions include both overt behaviors, 
such as hand washing or checking, and mental acts 
including counting or praying. Not uncommonly, 
compulsive rituals take up long periods of time, even 
hours, to complete. For example, repeated hand 
washing, intended to remedy anxiety about 
contamination, is a common cause of contact 
dermatitis. 

Although once thought to be rare, obsessive- 
compulsive disorder has now been documented to have 
a 1-year prevalence of 2.4 percent (Table 4-1). 
Obsessive-compulsive disorder is equally common 
among men and women. 

Obsessive-compulsive disorder typically begins in 
adolescence to young adult life (males) or in young 
adult life (females) (Burke et al., 1990; DSM-IV). For 
most, the course is fluctuating and, like generalized 
anxiety disorder, symptom exacerbations are usually 
associated with life stress. Common comorbidities 
include major depressive disorder and other anxiety 
disorders. Approximately 20 to 30 percent of people in 
clinical samples with obsessive-compulsive disorder 
report a past history of tics, and about one-quarter of 
these people meet the full criteria for Tourette's 
disorder (DSM-IV). Conversely, up to 50 percent of 
people with Tourette's disorder develop obsessive- 
compulsive disorder (Pitman et al., 1987). 

Obsessive-compulsive disorder has a clear familial 
pattern and somewhat greater familial specificity than 
most other anxiety disorders. Furthermore, there is an 
increased risk of obsessive-compulsive disorder among 
first-degree relatives with Tourette's disorder. Other 
mental disorders that may fall within the spectrum of 
obsessive-compulsive disorder include trichotillomania 
(compulsive hair pulling), compulsive shoplifting, 
gambling, and sexual behavior disorders (Hollander, 
1996). The latter conditions are somewhat discrepant 
because the compulsive behaviors are less ritualistic 
and yield some outcomes that are pleasurable or 



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gratifying. Body dysmorphic disorder is a more 
circumscribed condition in which the compulsive and 
obsessive behavior centers around a preoccupation with 
one's appearance (i.e., the syndrome of imagined 
ugliness) (Phillips, 1991). 

Acute and Post-Traumatic Stress Disorders 

Acute stress disorder refers to the anxiety and 
behavioral disturbances that develop within the first 
month after exposure to an extreme trauma. Generally, 
the symptoms of an acute stress disorder begin during 
or shortly following the trauma. Such extreme 
traumatic events include rape or other severe physical 
assault, near-death experiences in accidents, witnessing 
a murder, and combat. The symptom of dissociation, 
which reflects a perceived detachment of the mind from 
the emotional state or even the body, is a critical 
feature. Dissociation also is characterized by a sense of 
the world as a dreamlike or unreal place and may be 
accompanied by poor memory of the specific events, 
which in severe form is known as dissociative amnesia. 
Other features of an acute stress disorder include 
symptoms of generalized anxiety and hyperarousal, 
avoidance of situations or stimuli that elicit memories 
of the trauma, and persistent, intrusive recollections of 
the event via flashbacks, dreams, or recurrent thoughts 
or visual images. 

If the symptoms and behavioral disturbances of the 
acute stress disorder persist for more than 1 month, and 
if these features are associated with functional 
impairment or significant distress to the sufferer, the 
diagnosis is changed to post-traumatic stress disorder. 
Post-traumatic stress disorder is further defined in 
DSM-FV as having three subforms: acute' (< 3 months' 
duration), chronic (> 3 months' duration), and delayed 
onset (symptoms began at least 6 months after exposure 
to the trauma). 

By virtue of the more sustained nature of post- 



The acute subform of post-traumatic stress disorder is distinct 
from acute stress disorder because the latter resolves by the end 
of the first month, whereas the former persists until 3 months. 
If the condition persists after 3 months duration, the diagnosis is 
again changed to the chronic post-traumatic stress disorder 
subform (DSM-IV). 



traumatic stress disorder (relative to acute stress 
disorder), a number of changes, including decreased 
self-esteem, loss of sustained beliefs about people or 
society, hopelessness, a sense of being permanently 
damaged, and difficulties in previously established 
relationships, are typically observed. Substance abuse 
often develops, especially involving alcohol, marijuana, 
and sedative-hypnotic drugs. 

About 50 percent of cases of post-traumatic stress 
disorder remit within 6 months. For the remainder, the 
disorder typically persists for years and can dominate 
the sufferer's life. A longitudinal study of Vietnam 
veterans, for example, found 15 percent of veterans to 
be suffering from post-traumatic stress disorder 19 
years after combat exposure (cited in McFarlane & 
Yehuda, 1996). In the general population, the 1-year 
prevalence is about 3.6 percent, with women having 
almost twice the prevalence of men (Kessler et al., 
1995) (Table 4-1). The highest rates of post-traumatic 
stress disorder are found among women who are 
victims of crime, especially rape, as well as among 
torture and concentration camp survivors (Yehuda, 
1999). Overall, among those exposed to extreme 
trauma, about 9 percent develop post-traumatic stress 
disorder (Breslau et al., 1998). 

Etiology of Anxiety Disorders 

The etiology of most anxiety disorders, although not 
fully understood, has come into sharper focus in the last 
decade. In broad terms, the likelihood of developing 
anxiety involves a combination of life experiences, 
psychological traits, and/or genetic factors. The anxiety 
disorders are so heterogeneous that the relative roles of 
these factors are likely to differ. Some anxiety dis- 
orders, like panic disorder, appear to have a stronger 
genetic basis than others (National Institute of Mental 
Health [NIMH], 1998), although actual genes have not 
been identified. Other anxiety disorders are more 
rooted in stressful life events. 

It is not clear why females have higher rates than 
males of most anxiety disorders, although some 
theories have suggested a role for the gonadal steroids. 
Other research on women's responses to stress also 
suggests that women experience a wider range of life 



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events (e.g., those happening to friends) as stressful as 
compared with men who react to a more limited range 
of stressful events, specifically those affecting 
themselves or close family members (Maciejewski et 
al., 1999). 

What the myriad of anxiety disorders have in 
common is a state of increased arousal or fear (Barbee, 
1998). Anxiety disorders often are conceptualized as an 
abnormal or exaggerated version of arousal. Much is 
known about arousal because of decades of study in 
animals" and humans of the so-called "fight-or-flight 
response," which also is referred to as the acute stress 
response. The acute stress response is critical to 
understanding the normal response to stressors and has 
galvanized research, but its limitations for 
understanding anxiety have come to the forefront in 
recent years, as this section later explains. 

In common parlance, the term "stress" refers either 
to the external stressor, which can be physical or 
psychosocial in nature, as well as to the internal 
response to the stressor. Yet researchers distinguish the 
two, calling the stressor the stimulus and the body's 
reaction the stress response. This is an important 
distinction because in many anxiety states there is no 
immediate external stressor. The following paragraphs 
describe the biology of the acute stress response, as 
well as its limitations, in understanding human anxiety. 
Emerging views about the neurobiology of anxiety 
attempt to integrate and understand psychosocial views 
of anxiety and behavior in relation to the structure and 
function of the central and peripheral nervous system. 

Acute Stress Response 

When a fearful or threatening event is perceived, 
humans react innately to survive: they either are ready 
for battle or run away (hence the term "fight-or-flight 
response"). The nature of the acute stress response is 
all too familiar. Its hallmarks are an almost 
instantaneous surge in heart rate, blood pressure, 
sweating, breathing, and metabolism, and a tensing of 

^ Anxiety is one of the few mental disorders for which animal 
models have beendeveloped. Researchers can reproduce some 
of the symptoms of human anxiety in animals by introducing 
different types of stressors, either physical or psychosocial. 



muscles. Enhanced cardiac output and accelerated 
metabolism are essential for mobilizing fast action. The 
host of physiological changes activated by a stressful 
event are unleashed in part by activation of a nucleus in 
the brain stem called the locus ceruleus. This nucleus 
is the origin of most norepinephrine pathways in the 
brain. Neurons using norepinephrine as their 
neurotransmitter project bilaterally from the locus 
ceruleus along distinct pathways to the cerebral cortex, 
limbic system, and the spinal cord, among other 
projections. 

Normally, when someone is in a serene, unstim- 
ulated state, the "firing" of neurons in the locus 
ceruleus is minimal. A novel stimulus, once perceived, 
is relayed from the sensory cortex of the brain through 
the thalamus to the brain stem. That route of signaling 
increases the rate of noradrenergic activity in the locus 
ceruleus, and the person becomes alert and attentive to 
the environment. If the stimulus is perceived as a threat, 
a more intense and prolonged discharge of the locus 
ceruleus activates the sympathetic division of the 
autonomic nervous system (Thase & Howland, 1995). 
The activation of the sympathetic nervous system leads 
to the release of norepinephrine from nerve endings 
acting on the heart, blood vessels, respiratory centers, 
and other sites. The ensuing physiological changes 
constitute a major part of the acute stress response. The 
other major player in the acute stress response is the 
hypothalamic-pituitary-adrenal axis, which is discussed 
in the next section. 

In the 1980s, the prevailing view was that excess 
discharge of the locus ceruleus with the acute stress 
response was a major contributor to the etiology of 
anxiety (Coplan & Lydiard, 1998). Yet over the past 
decade, the limitations of the acute stress response as a 
model for understanding anxiety have become more 
apparent. The first and most obvious limitation is that 
the acute stress response relates to arousal rather than 
anxiety. Anxiety differs from arousal in several ways 
(Barlow, 1988; Nutt et al., 1998). First, with anxiety, 
the concern about the stressor is out of proportion to 
the realistic threat. Second, anxiety is often associated 
with elaborate mental and behavioral activities 
designed to avoid the unpleasant symptoms of a full- 



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blown anxiety or panic attack. Third, anxiety is usually 
longer lived than arousal. Fourth, anxiety can occur 
without exposure to an external stressor. 

Other limitations of this model became evident 
from a lack of support from clinical and basic research 
(Coplan & Lydiard, 1998). Furthermore, with its 
emphasis on the neurotransmitter norepinephrine, the 
model could not explain why medications that acted on 
the neurotransmitter serotonin (the selective serotonin 
reuptake inhibitors, or SSRIs) helped to alleviate 
anxiety symptoms. In fact, these medications are 
becoming the first-line treatment for anxiety disorders 
(Kent et al., 1998). To probe the etiology of anxiety, 
researchers began to devote their energies to the study 
of other brain circuits and the neurotransmitters on 
which they rely. The locus ceruleus still participates in 
anxiety but is understood to play a lesser role. 

New Views About the Anatomical and 
Biochemical Basis of Anxiety 

An exciting new line of research proposes that anxiety 
engages a wide range of neurocircuits. This line of 
research catapults to prominence two key regulatory 
centers found in the cerebral hemispheres of the 
brain — the hippocampus and the amygdala. These 
centers, in turn, are thought to activate the 
hypothalamic-pituitary-adrenocortical (HPA) axis-' 
(Goddard & Chamey, 1997; Coplan & Lydiard, 1998; 
Sullivan et al., 1998). Researchers have long 
established the contribution of the HPA axis to anxiety 
but have been perplexed by how it is regulated. They 
are buoyed by new findings about the roles of the 
hippocampus and the amygdala. 

The hippocampus and the amygdala govern 
memory storage and emotions, respectively, among 
their other functions. The hippocampus is considered 
important in verbal memory, especially of time and 
place for events with strong emotional overtones 
(McEwen, 1998). The hippocampus and amygdala are 
major nuclei of the limbic system, a pathway known to 



Hypothalamus and the pituitary gland, and then the cortex, 
or outer layer, of the adrenal gland. Upon stimulation by the 
pituitary hormone ACTH, the adrenal cortex releases gluco- 
corticoids into the circulation. 



underlie emotions. There are anatomical projections 
between the hippocampus, amygdala, and hypothal- 
alamus (Jacobson & Sapolsky, 1991; Chamey & 
Deutch, 1996; Coplan & Lydiard, 1998). 

Studies of emotional processing in rodents 
(LeDoux, 1996;Rogan&LeDoux, 1996; Davis, 1997) 
and in humans with brain lesions (Adolphs et al., 1998) 
have identified the amygdala as critical to fear 
responses. Sensory information enters the lateral 
amygdala, from which processed information is passed 
to the central nucleus, the major output nucleus of the 
amygdala. The central nucleus projects, in turn, to 
multiple brain systems involved in the physiologic and 
behavioral responses to fear. Projections to different 
regions of the hypothalamus activate the sympathetic 
nervous system and induce the release of stress 
hormones, such as CRH."^ The production of CRH in 
the paraventricular nucleus of the hypothalamus 
activates a cascade leading to release of glucocorticoids 
from the adrenal cortex. Projections from the central 
nucleus innervate different parts of the periaqueductal 
gray matter, which initiates descending analgesic 
responses (involving the body's endogenous opioids) 
that can suppress pain in an emergency, and which also 
activates species-typical defensive responses (e.g., 
many animals freeze when fearful). 

Anxiety differs from fear in that the fear-producing 
stimulus is either not present or not immediately 
threatening, but in anticipation of danger, the same 
arousal, vigilance, physiologic preparedness, and 
negative affects and cognitions occur. Different types 
of internal or external factors or triggers act to produce 
the anxiety symptoms of panic disorder, agoraphobia, 
post-traumatic stress disorder, specific phobias, and 
generalized anxiety disorder, and the prominent anxiety 
that commonly occurs in major depression. It is 
currently a matter of research to determine whether 
dysregulation of these fear pathways leads to the 
symptoms of anxiety disorders. It has now been 
es